pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	pbp_b16a_maxenr_mc_yn	pbp_b16a_maxenr_mc_amt	pbp_b16a_maxenr_mc_per	pbp_b16a_maxenr_mc_per_desc	pbp_b16a_coins_mc_yn	pbp_b16a_coins_mc_pct	pbp_b16a_coins_mc_pct_min	pbp_b16a_coins_mc_pct_max	pbp_b16a_copay_mc_yn	pbp_b16a_copay_mc_amt	pbp_b16a_copay_mc_amt_min	pbp_b16a_copay_mc_amt_max	pbp_b16a_ded_mc_yn	pbp_b16a_ded_mc_amt	pbp_b16a_auth_mc_yn	pbp_b16a_refer_mc_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_maxplan_excl_csg_yn	pbp_b16b_maxplan_csg_groups	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_maxplan_excl_csg_yn	pbp_b16c_maxplan_csg_groups	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
H0016	001	0	1	20	08	H0016_001_0	1																																																																																																																																																																																																																																																																																																						
H0016	003	0	1	20	08	H0016_003_0	1																																																																																																																																																																																																																																																																																																						
H0028	007	0	1	01	01	H0028_007_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	014	0	1	01	01	H0028_014_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H0028	015	0	1	02	01	H0028_015_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	016	0	1	02	01	H0028_016_0	7	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H0028	017	0	1	01	01	H0028_017_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H0028	019	0	1	01	01	H0028_019_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	021	0	1	01	01	H0028_021_0	5	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H0028	024	0	1	01	01	H0028_024_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	028	0	1	01	01	H0028_028_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	029	0	1	01	01	H0028_029_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H0028	030	0	1	01	01	H0028_030_0	5	2				2				1	20.00	20.00	20.00	2		1	1	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	032	0	1	01	01	H0028_032_0	4	2				1	20	20	20	2				2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	035	0	1	01	01	H0028_035_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	036	0	1	01	01	H0028_036_0	4	2				1	20	20	20	2				2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	037	0	1	01	01	H0028_037_0	5	2				2				1	25.00	25.00	25.00	2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H0028	039	0	1	01	01	H0028_039_0	5	2				2				1	10.00	10.00	10.00	2		1	1	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H0028	041	0	1	01	01	H0028_041_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	042	0	1	01	01	H0028_042_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	043	1	1	01	01	H0028_043_1	4	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	043	2	1	01	01	H0028_043_2	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	046	0	1	01	01	H0028_046_0	5	2				2				1	20.00	20.00	20.00	2		1	1	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H0028	051	0	1	01	01	H0028_051_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H0028	053	1	1	01	01	H0028_053_1	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H0028	053	3	1	01	01	H0028_053_3	5	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H0028	054	1	1	02	01	H0028_054_1	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H0028	054	2	1	02	01	H0028_054_2	5	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H0028	055	0	1	02	01	H0028_055_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H0028	056	0	1	02	01	H0028_056_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H0028	059	0	1	01	01	H0028_059_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H0028	060	0	1	01	01	H0028_060_0	6	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	062	0	1	01	01	H0028_062_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	063	0	1	01	01	H0028_063_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	065	0	1	01	01	H0028_065_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H0028	066	0	1	02	01	H0028_066_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	067	0	1	02	01	H0028_067_0	5	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	070	0	1	01	01	H0028_070_0	5	2				2				1	15.00	15.00	15.00	2		1	1	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	072	0	1	01	01	H0028_072_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	074	1	1	01	01	H0028_074_1	5	2				2				1	15.00	15.00	15.00	2		1	2	1		4000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	074	2	1	01	01	H0028_074_2	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1750.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	076	0	1	01	01	H0028_076_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	077	0	1	01	01	H0028_077_0	4	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	078	0	1	01	01	H0028_078_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	079	0	1	01	01	H0028_079_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	080	0	1	01	01	H0028_080_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	081	1	1	01	01	H0028_081_1	5	2				2				1	20.00	20.00	20.00	2		1	2	1		2500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	081	2	1	01	01	H0028_081_2	5	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H0028	082	0	1	01	01	H0028_082_0	6	2				2				1	40.00	40.00	40.00	2		1	1	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	1	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H0028	801	0	1	01	01	H0028_801_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0028	802	0	1	01	01	H0028_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0028	804	0	1	01	01	H0028_804_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0028	805	0	1	01	01	H0028_805_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0029	007	0	1	01	01	H0029_007_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0029	008	0	1	02	01	H0029_008_0	4	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0034	001	0	1	01	01	H0034_001_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2								2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0034	002	0	1	01	01	H0034_002_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2								2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0062	011	0	1	01	01	H0062_011_0	7	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0062	012	0	1	01	01	H0062_012_0	7	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0062	013	0	1	01	01	H0062_013_0	5	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H0074	001	0	1	04	01	H0074_001_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	1	40	40	40	2				1	2	2	2	1	6	Once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	Every 6 months to 2 years	1	40	40	40	2				1	2	2	2	1	6	Every year to 5 years	1	40	40	40	2				1	2																																														2	2	1	6	Per tooth per lifetime	1	40	40	40	2				1	2																2	2	1	6	Every date of service to every 5 years	1	40	40	40	2				1	2
H0074	004	0	1	04	01	H0074_004_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0104	012	0	1	04	01	H0104_012_0	7	2				2				1	40.00	40.00	40.00	2		2	2	1	2	650.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0104	014	0	1	04	01	H0104_014_0	7	2				2				1	40.00	40.00	40.00	2		2	2	1	2	650.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0104	016	0	1	04	01	H0104_016_0	8	2				2				1	40.00	40.00	40.00	2		2	2	1	2	375.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																																																																																																																																																					
H0104	801	0	1	04	01	H0104_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0104	802	0	1	04	01	H0104_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0104	804	0	1	04	01	H0104_804_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0104	805	0	1	04	01	H0104_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0104	806	0	1	04	01	H0104_806_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0104	807	0	1	04	01	H0104_807_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0104	808	0	1	04	01	H0104_808_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0104	809	0	1	04	01	H0104_809_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0105	001	0	1	20	08	H0105_001_0	1																																																																																																																																																																																																																																																																																																						
H0105	002	0	1	20	08	H0105_002_0	1																																																																																																																																																																																																																																																																																																						
H0107	801	0	1	04	01	H0107_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0107	802	0	1	04	01	H0107_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0107	803	0	1	04	01	H0107_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0107	806	0	1	04	01	H0107_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0107	813	0	1	04	01	H0107_813_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0107	817	0	1	04	01	H0107_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0107	821	0	1	04	01	H0107_821_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0111	001	0	1	04	01	H0111_001_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0111	004	0	1	04	01	H0111_004_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0111	007	0	1	04	01	H0111_007_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0112	001	0	1	20	08	H0112_001_0	1																																																																																																																																																																																																																																																																																																						
H0112	002	0	1	20	08	H0112_002_0	1																																																																																																																																																																																																																																																																																																						
H0154	008	0	1	01	01	H0154_008_0	3	2				2				2				2		2	2	1		1250.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	011	0	1	01	01	H0154_011_0	5	2				2				2				2		2	2	1		1300.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	012	0	1	01	01	H0154_012_0	5	2				2				2				2		2	2	1		1150.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	015	1	1	01	01	H0154_015_1	7	2				2				2				2		2	2	1		1100.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	015	2	1	01	01	H0154_015_2	6	2				2				2				2		2	2	1		725.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	017	0	1	01	01	H0154_017_0	4	2				2				2				2		2	2	1		800.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	019	0	1	01	01	H0154_019_0	5	2				2				2				2		2	2	1		1500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	020	0	1	01	01	H0154_020_0	4	2				2				2				2		2	2	1		1400.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	021	0	1	01	01	H0154_021_0	5	2				2				2				2		2	2	1		1075.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	801	0	1	01	01	H0154_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0154	802	0	1	01	01	H0154_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0154	803	0	1	01	01	H0154_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0169	001	0	1	02	01	H0169_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0169	002	0	1	02	01	H0169_002_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0169	004	0	1	02	01	H0169_004_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0169	010	0	1	02	01	H0169_010_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0169	014	1	1	02	01	H0169_014_1	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0169	014	2	1	02	01	H0169_014_2	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0169	014	3	1	02	01	H0169_014_3	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0169	015	1	1	02	01	H0169_015_1	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0169	015	2	1	02	01	H0169_015_2	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0169	015	3	1	02	01	H0169_015_3	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0169	016	0	1	02	01	H0169_016_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0174	004	0	1	01	01	H0174_004_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0174	010	0	1	01	01	H0174_010_0	5	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0174	014	0	1	01	01	H0174_014_0	5	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0174	015	0	1	01	01	H0174_015_0	5	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0174	016	0	1	01	01	H0174_016_0	5	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0174	022	0	1	01	01	H0174_022_0	6	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0174	023	0	1	01	01	H0174_023_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0174	024	0	1	01	01	H0174_024_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0174	025	0	1	01	01	H0174_025_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0174	026	0	1	01	01	H0174_026_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0174	027	1	1	01	01	H0174_027_1	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3				2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0174	027	2	1	01	01	H0174_027_2	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3				2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0216	001	0	1	20	08	H0216_001_0	1																																																																																																																																																																																																																																																																																																						
H0216	002	0	1	20	08	H0216_002_0	1																																																																																																																																																																																																																																																																																																						
H0235	001	0	1	20	08	H0235_001_0	1																																																																																																																																																																																																																																																																																																						
H0235	002	0	1	20	08	H0235_002_0	1																																																																																																																																																																																																																																																																																																						
H0251	004	0	1	02	01	H0251_004_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0251	009	1	1	02	01	H0251_009_1	4	2				1	20	20	20	2				2		1	2	1		3500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0251	009	2	1	02	01	H0251_009_2	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0251	009	3	1	02	01	H0251_009_3	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0251	010	1	1	02	01	H0251_010_1	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0251	010	2	1	02	01	H0251_010_2	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0251	010	3	1	02	01	H0251_010_3	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0270	801	0	1	04	01	H0270_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0279	801	0	1	04	01	H0279_801_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0279	802	0	1	04	01	H0279_802_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0279	803	0	1	04	01	H0279_803_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0292	001	0	1	01	01	H0292_001_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0292	002	0	1	01	01	H0292_002_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0292	003	0	1	01	01	H0292_003_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0292	004	0	1	02	01	H0292_004_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0294	002	0	1	04	01	H0294_002_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0294	004	0	1	04	01	H0294_004_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0294	014	0	1	04	01	H0294_014_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0294	015	0	1	04	01	H0294_015_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0294	017	0	1	04	01	H0294_017_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0294	018	0	1	04	01	H0294_018_0	6	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0294	022	0	1	04	01	H0294_022_0	3	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0294	027	0	1	04	01	H0294_027_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0294	032	0	1	04	01	H0294_032_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0294	048	0	1	04	01	H0294_048_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0294	050	0	1	04	01	H0294_050_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0294	051	0	1	04	01	H0294_051_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0294	052	1	1	04	01	H0294_052_1	4	2				1	20	20	20	2				2		1	2	1	2	2750.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0294	052	2	1	04	01	H0294_052_2	4	2				1	20	20	20	2				2		1	2	1	2	2750.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0302	001	0	1	01	01	H0302_001_0	8	2				1	20	20	20	2				2		2	2	2							2				2					1	110111	10.00	10.00	10.00	2		2	2	2	6	Two evaluations per Calendar Year, including a maximum of one comprehensive evaluation per 36 monthsOne emergency or problem-focused exam per Calendar YearOne detailed and extensive oral evaluation	2								2	2	2	2	2	6	Bitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50					2	2	1	2		3000.00	3		2		2					2		2	2	1	6	7-year replacement limit	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	one per tooth per lifetime and one per tooth per 24 months for retreatment	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per quadrant per 24 months	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	Per 7 years	1	50	50	50	1	10.00	10.00	10.00	2	2																2	2	1	6	One per 7 years	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per 7 years and one per 12 months for re-cement or re-bond	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime	1	50	50	50	1	10.00	10.00	10.00	2	2																														
H0302	006	0	1	01	01	H0302_006_0	6	2				2				1	10.00	10.00	10.00	2		2	2	2							2				2					1	110111	10.00	10.00	10.00	2		2	2	2	6	Two evaluations per Calendar Year, including a maximum of one comprehensive evaluation per 36 monthsOne emergency or problem-focused exam per Calendar YearOne detailed and extensive oral evaluation	2								2	2	2	2	2	6	Bitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50					2	2	1	2		2000.00	3		2		2					2		2	2	1	6	7 year replacement limit	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime and one per tooth per 24 months for retreatment	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per quadrant per 24 months	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	Per 7 years	1	50	50	50	1	10.00	10.00	10.00	2	2																															2	2	1	6	One per 7 years and one per 12 months for re-cement or re-bond	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime	1	50	50	50	1	10.00	10.00	10.00	2	2																														
H0302	008	0	1	01	01	H0302_008_0	6	2				2				1	10.00	10.00	10.00	2		2	2	2							2				2					1	110111	10.00	10.00	10.00	2		2	2	2	6	Two evaluations per Calendar Year, including a maximum of one comprehensive evaluation per 36 monthsOne emergency or problem-focused exam per Calendar YearOne detailed and extensive oral evaluation	2								2	2	2	2	2	6	Bitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50					2	2	1	2		2000.00	3		2		2					2		2	2	1	6	7 year replacement limit	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime and one per tooth per 24 months for retreatment	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per quadrant per 24 months	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	Per 7 years	1	50	50	50	1	10.00	10.00	10.00	2	2																															2	2	1	6	One per 7 years and one per 12 months for re-cement or re-bond	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime	1	50	50	50	1	10.00	10.00	10.00	2	2																														
H0302	010	0	1	01	01	H0302_010_0	6	2				2				1	10.00	10.00	10.00	2		2	2	2							2				2					1	110111	10.00	10.00	10.00	2		2	2	2	6	Two evaluations per Calendar Year, including a maximum of one comprehensive evaluation per 36 monthsOne emergency or problem-focused exam per Calendar YearOne detailed and extensive oral evaluation	2								2	2	2	2	2	6	Bitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50					2	2	1	2		1000.00	3		2		2					2		2	2	1	6	7 year replacement limit	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime and one per tooth per 24 months for retreatment	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per quadrant per 24 months	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	Per 7 years	1	50	50	50	1	10.00	10.00	10.00	2	2																															2	2	1	6	One per 7 years and one per 12 months for re-cement or re-bond	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime	1	50	50	50	1	10.00	10.00	10.00	2	2																														
H0302	011	0	1	01	01	H0302_011_0	6	2				2				1	10.00	10.00	10.00	2		2	2	2							2				2					1	110111	10.00	10.00	10.00	2		2	2	2	6	Two evaluations per Calendar Year, including a maximum of one comprehensive evaluation per 36 monthsOne emergency or problem-focused exam per Calendar YearOne detailed and extensive oral evaluation	2								2	2	2	2	2	6	Bitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50					2	2	1	2		1000.00	3		2		2					2		2	2	1	6	7 year replacement limit	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime and one per tooth per 24 months for retreatment	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per quadrant per 24 months	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	Per 7 years	1	50	50	50	1	10.00	10.00	10.00	2	2																															2	2	1	6	One per 7 years and one per 12 months for re-cement or re-bond	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime	1	50	50	50	1	10.00	10.00	10.00	2	2																														
H0302	801	0	1	01	01	H0302_801_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0321	002	0	1	02	01	H0321_002_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0321	004	0	1	02	01	H0321_004_0	4	2				1	20	20	20	2				2		1	2	1		4500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0332	001	0	1	01	01	H0332_001_0	10	2				2				2				2		2	2	1		1500.00	3		2		2				2					2					1	25.00	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2																															1	1							2					2		2	2	1	3		2				2				2	2																																																																																											2	2	1	6	One per tooth per lifetime (D7140 and D7210)	2				2				2	2																2	2	1	3		2				2				2	2
H0332	004	0	1	02	01	H0332_004_0	12	2				2				1	35.00	35.00	35.00	2		2	2	1		2000.00	3		2		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2																															1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	2	1	3		2				2				2	2
H0332	009	0	1	01	01	H0332_009_0	13	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3		2		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2																															1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	2	1	3		2				2				2	2
H0332	801	0	1	01	01	H0332_801_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	803	0	1	01	01	H0332_803_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	804	0	1	01	01	H0332_804_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	805	0	1	01	01	H0332_805_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	806	0	1	01	01	H0332_806_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	807	0	1	01	01	H0332_807_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	808	0	1	01	01	H0332_808_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	809	0	1	01	01	H0332_809_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	810	0	1	01	01	H0332_810_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	811	0	1	01	01	H0332_811_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	812	0	1	01	01	H0332_812_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	813	0	1	01	01	H0332_813_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	814	0	1	01	01	H0332_814_0	8	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	815	0	1	01	01	H0332_815_0	7	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0332	816	0	1	01	01	H0332_816_0	7	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0351	038	0	1	01	01	H0351_038_0	7	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	Once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	Every 6 months to 2 years	1	40	40	40	2				1	2																																																													2	2	1	6	Per tooth per lifetime	1	40	40	40	2				1	2																2	2	1	6	Every date of service to every 5 years	1	40	40	40	2				1	2
H0351	063	0	1	01	01	H0351_063_0	7	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth Every 7 plan years. Other restorative Every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per plan year, and once per same tooth Every 7 plan years; other implant services Every year to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth Every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0351	066	0	1	02	01	H0351_066_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0351	068	0	1	02	01	H0351_068_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0351	071	0	1	01	01	H0351_071_0	7	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H0354	027	0	1	01	01	H0354_027_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				3		0.00	240.00	2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	620.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	575.00	2	2	2	1				2				3		25.00	450.00	2	2																2	1				2				3		0.00	950.00	2	2	2	1				2				3		0.00	525.00	2	2	2	1				2				3		0.00	455.00	2	2																2	1				2				3		0.00	260.00	2	2
H0354	028	0	1	01	01	H0354_028_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		1650.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0354	029	0	1	01	01	H0354_029_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0354	030	0	1	01	01	H0354_030_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0354	804	0	1	01	01	H0354_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0354	805	0	1	01	01	H0354_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0363	001	0	1	01	01	H0363_001_0	6	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0390	001	0	1	20	08	H0390_001_0	1																																																																																																																																																																																																																																																																																																						
H0390	002	0	1	20	08	H0390_002_0	3																																																																																																																																																																																																																																																																																																						
H0413	001	0	1	04	01	H0413_001_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H0413	002	0	1	04	01	H0413_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H0413	003	0	1	04	01	H0413_003_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H0413	004	0	1	04	01	H0413_004_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H0413	005	0	1	04	01	H0413_005_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H0421	001	0	1	04	01	H0421_001_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0423	001	0	1	01	01	H0423_001_0	8	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2								2					2		2	2	1	2		2				2				1	2	2	2	1	6	per 1 Lifetime Per patient, Same tooth	2				2				1	2	2	2	1	6	Please see noted below.	2				2				1	2	2	2	1	6	Please see notes below.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	per patient- same tooth, every 96 months	2				2				1	2	2	2	1	6	per patient- same tooth, evert 60 months	2				2				1	2	2	2	1	6	One per lifetime, per patient, same quadrant.	2				2				1	2	2	2	1	6	Please see notes below.	2				2				1	2	2	2	1	6	Please see noted below.	2				2				1	2
H0423	004	0	1	01	01	H0423_004_0	8	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	2		1500.00	3		2		2					2		2	2	1	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	1 every 60 months, per tooth	2				2				1	2																															2	2	1	6	every 60 months	2				2				1	2																																													
H0423	007	0	1	01	01	H0423_007_0	8	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2								2					2		2	2	1	2		2				2				1	2	2	2	1	6	per 1 Lifetime Per patient, Same tooth	2				2				1	2	2	2	1	6	Please see noted below.	2				2				1	2	2	2	1	6	Please see notes below.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	per patient- same tooth, every 96 months	2				2				1	2	2	2	1	6	per patient- same tooth, evert 60 months	2				2				1	2	2	2	1	6	One per lifetime, per patient, same quadrant.	2				2				1	2	2	2	1	6	Please see notes below.	2				2				1	2	2	2	1	6	Please see noted below.	2				2				1	2
H0424	001	0	1	20	08	H0424_001_0	1																																																																																																																																																																																																																																																																																																						
H0424	002	0	1	20	08	H0424_002_0	1																																																																																																																																																																																																																																																																																																						
H0432	003	0	1	02	01	H0432_003_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0432	004	0	1	02	01	H0432_004_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0432	009	0	1	02	01	H0432_009_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0432	012	0	1	02	01	H0432_012_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0432	017	0	1	02	01	H0432_017_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0432	801	0	1	01	01	H0432_801_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0439	002	0	1	01	01	H0439_002_0	7	2				2				2				2		1	2	1		2500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	003	1	1	01	01	H0439_003_1	6	2				2				1	40.00	40.00	40.00	2		1	2	1		650.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	003	2	1	01	01	H0439_003_2	6	2				2				1	50.00	50.00	50.00	2		1	2	1		550.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	008	0	1	01	01	H0439_008_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		550.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	009	0	1	01	01	H0439_009_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	010	0	1	01	01	H0439_010_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		1200.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	011	0	1	01	01	H0439_011_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		1200.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	012	0	1	01	01	H0439_012_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	015	1	1	01	01	H0439_015_1	6	2				2				1	35.00	35.00	35.00	2		1	2	1		800.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	015	2	1	01	01	H0439_015_2	6	2				2				1	35.00	35.00	35.00	2		1	2	1		650.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	016	0	1	01	01	H0439_016_0	7	2				2				1	50.00	50.00	50.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	017	0	1	01	01	H0439_017_0	7	2				2				1	50.00	50.00	50.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	018	0	1	01	01	H0439_018_0	7	2				2				1	50.00	50.00	50.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	019	0	1	01	01	H0439_019_0	7	2				2				1	50.00	50.00	50.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	020	0	1	01	01	H0439_020_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	021	0	1	01	01	H0439_021_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	022	0	1	01	01	H0439_022_0	6	2				1	20	20	20	2				2		1	2	1		2700.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	023	0	1	01	01	H0439_023_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	801	0	1	01	01	H0439_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0440	001	0	1	20	08	H0440_001_0	1																																																																																																																																																																																																																																																																																																						
H0440	002	0	1	20	08	H0440_002_0	1																																																																																																																																																																																																																																																																																																						
H0473	003	0	1	04	01	H0473_003_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0473	004	0	1	04	01	H0473_004_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H0473	005	0	1	04	01	H0473_005_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H0477	001	0	1	20	08	H0477_001_0	1																																																																																																																																																																																																																																																																																																						
H0477	002	0	1	20	08	H0477_002_0	1																																																																																																																																																																																																																																																																																																						
H0504	015	0	1	01	01	H0504_015_0	8	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive oral evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2								2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity range: Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation covered once every 6 months from last date of service, periodontal maintenance covered once every 5 years from last date of service.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity range: No frequency limit for soft liner for complete or partial removable denture  indirect, immediate denture  maxillary covered once per lifetime.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic  indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	017	0	1	01	01	H0504_017_0	8	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive oral evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2								2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity range: Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation covered once every 6 months from last date of service, periodontal maintenance covered once every 5 years from last date of service.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity range: No frequency limit for soft liner for complete or partial removable denture  indirect, immediate denture  maxillary covered once per lifetime.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic  indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	021	0	1	01	01	H0504_021_0	8	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive oral evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2								2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity range: Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation covered once every 6 months from last date of service, periodontal maintenance covered once every 5 years from last date of service.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity range: No frequency limit for soft liner for complete or partial removable denture  indirect, immediate denture  maxillary covered once per lifetime.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic  indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	026	0	1	01	01	H0504_026_0	8	2				2				2				2		2	1																																																																																																																																																																																																																																																																																						
H0504	028	0	1	01	01	H0504_028_0	8	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive oral evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2								2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity range: Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation covered once every 6 months from last date of service, periodontal maintenance covered once every 5 years from last date of service.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity range: No frequency limit for soft liner for complete or partial removable denture  indirect, immediate denture  maxillary covered once per lifetime.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic  indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	038	0	1	01	01	H0504_038_0	8	2				2				2				2		2	1																																																																																																																																																																																																																																																																																						
H0504	039	0	1	01	01	H0504_039_0	7	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 months from last date of service.	3		0	20	2				2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	4	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, caries risk assessment and documentation with a finding of moderate risk covered twice every 12 months from last date of service.	3		0	20	2				2	2	4	2	1	4		3		0	20	2				2	2	4	2	2	4		3		0	20	2				2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant  per tooth covered twice every 36 months (exact tooth) from last date of service.	3		0	20	2				2	2																																																																																																																																																																					
H0504	040	0	1	01	01	H0504_040_0	8	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive oral evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2								2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity range: Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation covered once every 6 months from last date of service, periodontal maintenance covered once every 5 years from last date of service.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity range: No frequency limit for soft liner for complete or partial removable denture  indirect, immediate denture  maxillary covered once per lifetime.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic  indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	041	0	1	01	01	H0504_041_0	8	2				2				3		0.00	10.00	2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, caries risk assessment and documentation with a finding of moderate risk covered twice every 12 months from last date of service.	2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant  per tooth covered twice every 36 months (exact tooth) from last date of service.	2				2				2	2																																																																																																																																																																					
H0504	043	0	1	01	01	H0504_043_0	8	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive oral evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2								2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity range: Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation covered once every 6 months from last date of service, periodontal maintenance covered once every 5 years from last date of service.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity range: No frequency limit for soft liner for complete or partial removable denture  indirect, immediate denture  maxillary covered once per lifetime.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic  indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	047	0	1	01	01	H0504_047_0	8	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, caries risk assessment and documentation with a finding of moderate risk covered twice every 12 months from last date of service.	2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant  per tooth covered twice every 36 months (exact tooth) from last date of service.	2				2				2	2																																																																																																																																																																					
H0504	050	0	1	01	01	H0504_050_0	7	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive oral evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2								2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity range: Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation covered once every 6 months from last date of service, periodontal maintenance covered once every 5 years from last date of service.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity range: No frequency limit for soft liner for complete or partial removable denture  indirect, immediate denture  maxillary covered once per lifetime.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic  indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	053	0	1	01	01	H0504_053_0	7	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, caries risk assessment and documentation with a finding of moderate risk covered twice every 12 months from last date of service.	2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				2				2	2																																																																																																																																																																					
H0504	054	0	1	01	01	H0504_054_0	7	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, caries risk assessment and documentation with a finding of moderate risk covered twice every 12 months from last date of service.	2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				2				2	2																																																																																																																																																																					
H0504	055	0	1	01	01	H0504_055_0	7	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, caries risk assessment and documentation with a finding of moderate risk covered twice every 12 months from last date of service.	2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				2				2	2																																																																																																																																																																					
H0504	056	0	1	01	01	H0504_056_0	7	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, caries risk assessment and documentation with a finding of moderate risk covered twice every 12 months from last date of service.	2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				2				2	2																																																																																																																																																																					
H0504	057	0	1	01	01	H0504_057_0	8	2				2				2				2		2	1	2							2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, caries risk assessment and documentation with a finding of moderate risk covered twice every 12 months from last date of service.	2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				2				2	2																																																																																																																																																																					
H0504	803	0	1	01	01	H0504_803_0	4	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																						
H0504	804	0	1	01	01	H0504_804_0	4	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																						
H0504	805	0	1	01	01	H0504_805_0	4	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																						
H0504	806	0	1	01	01	H0504_806_0	4	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																						
H0504	807	0	1	01	01	H0504_807_0	4	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																						
H0504	808	0	1	01	01	H0504_808_0	4	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																						
H0523	022	0	1	01	01	H0523_022_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H0523	065	0	1	01	01	H0523_065_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H0523	070	0	1	01	01	H0523_070_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0523	073	0	1	01	01	H0523_073_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1750.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0523	074	0	1	01	01	H0523_074_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0523	075	0	1	01	01	H0523_075_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0523	083	0	1	01	01	H0523_083_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0523	085	0	1	01	01	H0523_085_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0523	086	0	1	01	01	H0523_086_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H0523	088	0	1	01	01	H0523_088_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0523	089	0	1	01	01	H0523_089_0	3	2				2				1	5.00	5.00	5.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H0523	091	0	1	01	01	H0523_091_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H0523	094	0	1	01	01	H0523_094_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H0523	095	0	1	01	01	H0523_095_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H0523	096	0	1	01	01	H0523_096_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0523	097	0	1	01	01	H0523_097_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0523	098	0	1	01	01	H0523_098_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0523	099	0	1	01	01	H0523_099_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0523	801	0	1	01	01	H0523_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0523	805	0	1	01	01	H0523_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0523	808	0	1	01	01	H0523_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0524	003	0	1	01	01	H0524_003_0	7	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	008	0	1	01	01	H0524_008_0	6	2				2				3		0.00	15.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	013	0	1	01	01	H0524_013_0	6	2				2				3		0.00	15.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	015	0	1	01	01	H0524_015_0	6	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	031	0	1	01	01	H0524_031_0	6	2				2				3		0.00	15.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	032	0	1	01	01	H0524_032_0	6	2				2				3		0.00	15.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	033	0	1	01	01	H0524_033_0	6	2				2				3		0.00	15.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	034	0	1	01	01	H0524_034_0	7	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	035	0	1	01	01	H0524_035_0	6	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	036	0	1	01	01	H0524_036_0	7	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	037	0	1	01	01	H0524_037_0	6	2				2				3		0.00	15.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	038	0	1	01	01	H0524_038_0	6	2				2				3		0.00	15.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	039	0	1	01	01	H0524_039_0	6	2				2				3		0.00	20.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	040	0	1	01	01	H0524_040_0	6	2				2				3		0.00	10.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	041	0	1	01	01	H0524_041_0	6	2				2				3		0.00	20.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	042	0	1	01	01	H0524_042_0	6	2				2				3		0.00	10.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	043	0	1	01	01	H0524_043_0	6	2				2				3		0.00	20.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	046	0	1	01	01	H0524_046_0	6	2				2				3		0.00	30.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	051	0	1	01	01	H0524_051_0	6	2				2				3		0.00	30.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	054	0	1	01	01	H0524_054_0	6	2				2				3		0.00	25.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	059	0	1	01	01	H0524_059_0	6	2				2				3		0.00	30.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	060	0	1	01	01	H0524_060_0	6	2				2				3		0.00	30.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	061	0	1	01	01	H0524_061_0	7	2				2				3		0.00	30.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	062	0	1	01	01	H0524_062_0	6	2				2				3		0.00	30.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	063	0	1	01	01	H0524_063_0	6	2				2				3		0.00	30.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	064	0	1	01	01	H0524_064_0	6	2				2				3		0.00	30.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	065	0	1	01	01	H0524_065_0	6	2				2				3		0.00	30.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	078	0	1	01	01	H0524_078_0	6	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	081	0	1	01	01	H0524_081_0	6	2				2				3		0.00	15.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	082	0	1	01	01	H0524_082_0	6	2				2				3		0.00	35.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	083	0	1	01	01	H0524_083_0	6	2				2				3		0.00	5.00	2		1	1	2							2				2					1	111110	0.00	0.00	0.00	2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2								2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2								2	1	4	1				2								2	1	2	2	2	3		2								2	1	2	2	2	3		2								2	1	3													2	2	2								2					2		3													2	2	3													2	2	4	2	2	6	Periodontal maintenance or scaling in presence of generalized gingival inflammation limited to 2 per yr as part of a combined limit with prophylaxis. Scaling and root planing limited to 1 per quadrant every 2 yrs.	2				1	0.00	0.00	0.00	2	1	3													2	2																3													2	2	3													2	2	3													2	2																4	2	1	6	Palliative treatment limited to 1 visit per day.	2				1	0.00	0.00	0.00	2	1
H0524	801	0	1	01	01	H0524_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0524	802	0	1	01	01	H0524_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0524	803	0	2	01	01	H0524_803_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0524	804	0	2	01	01	H0524_804_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0524	805	0	1	01	01	H0524_805_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0524	806	0	1	01	01	H0524_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0524	807	0	2	01	01	H0524_807_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0524	808	0	2	01	01	H0524_808_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0542	001	0	1	20	08	H0542_001_0	2																																																																																																																																																																																																																																																																																																						
H0542	002	0	1	20	08	H0542_002_0	2																																																																																																																																																																																																																																																																																																						
H0543	013	0	1	02	01	H0543_013_0	6	2				1	20	20	20	2				2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	019	0	1	02	01	H0543_019_0	6	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	035	0	1	02	01	H0543_035_0	5	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	060	0	1	02	01	H0543_060_0	6	2				1	20	20	20	2				2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	086	0	1	02	01	H0543_086_0	5	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	121	0	1	02	01	H0543_121_0	2	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	140	0	1	02	01	H0543_140_0	4	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	145	0	1	02	01	H0543_145_0	6	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	151	0	1	02	01	H0543_151_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	152	0	1	02	01	H0543_152_0	6	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	166	0	1	02	01	H0543_166_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	168	0	1	02	01	H0543_168_0	6	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	169	0	1	02	01	H0543_169_0	6	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	170	0	1	02	01	H0543_170_0	6	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	188	0	1	02	01	H0543_188_0	4	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	191	0	1	02	01	H0543_191_0	4	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	204	0	1	02	01	H0543_204_0	6	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	214	0	1	02	01	H0543_214_0	6	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	217	0	1	02	01	H0543_217_0	6	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	218	0	1	02	01	H0543_218_0	6	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	219	0	1	02	01	H0543_219_0	6	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	220	0	1	02	01	H0543_220_0	6	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	221	0	1	02	01	H0543_221_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	222	0	1	02	01	H0543_222_0	4	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	225	0	1	02	01	H0543_225_0	6	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	226	0	1	02	01	H0543_226_0	6	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	232	0	1	02	01	H0543_232_0	4	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	236	0	1	02	01	H0543_236_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	237	0	1	02	01	H0543_237_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	238	0	1	02	01	H0543_238_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	239	0	1	01	01	H0543_239_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0543	240	0	1	01	01	H0543_240_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0543	241	0	1	01	01	H0543_241_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0543	242	0	1	01	01	H0543_242_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0543	246	0	1	01	01	H0543_246_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0543	249	0	1	02	01	H0543_249_0	4	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	254	0	1	02	01	H0543_254_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	255	0	1	02	01	H0543_255_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	258	0	1	02	01	H0543_258_0	2	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0543	260	0	1	02	01	H0543_260_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	262	0	1	02	01	H0543_262_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0543	802	0	1	01	01	H0543_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0543	805	0	1	01	01	H0543_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0543	806	0	1	01	01	H0543_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0543	810	0	1	01	01	H0543_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0544	002	0	1	02	01	H0544_002_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	004	0	1	02	01	H0544_004_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	005	0	1	01	01	H0544_005_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2								2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	010	0	1	02	01	H0544_010_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	014	0	1	02	01	H0544_014_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	015	0	1	02	01	H0544_015_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	019	0	1	02	01	H0544_019_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	020	0	1	02	01	H0544_020_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	056	0	1	02	01	H0544_056_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	058	0	1	02	01	H0544_058_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	061	0	1	02	01	H0544_061_0	5	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H0544	062	0	1	02	01	H0544_062_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	063	0	1	02	01	H0544_063_0	5	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H0544	065	0	1	02	01	H0544_065_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		750.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	066	0	1	02	01	H0544_066_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	069	0	1	02	01	H0544_069_0	5	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H0544	091	0	1	02	01	H0544_091_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		1400.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	096	0	1	02	01	H0544_096_0	4	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H0544	805	0	1	01	01	H0544_805_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0544	806	0	1	01	01	H0544_806_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0544	808	0	2	01	01	H0544_808_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0544	809	0	2	01	01	H0544_809_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0544	810	0	1	01	01	H0544_810_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0544	812	0	2	01	01	H0544_812_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0544	813	0	1	01	01	H0544_813_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0562	012	0	1	01	01	H0562_012_0	7	2				2				1	5.00	5.00	5.00	2		1	2	2							2				2					2					2		2	2	2	6	Every year to every 3 plan years	2				1	10.00	10.00	10.00	1	2	2	2	1	6	Every date of service to 3 years	2				3		0.00	20.00	1	2	2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	10.00	10.00	10.00	1	2	2	2	1	3		2				1	10.00	10.00	10.00	1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	540.00	1	2	2	1				2				3		35.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		35.00	250.00	1	2																2	1				2				3		0.00	150.00	1	2
H0562	092	0	1	01	01	H0562_092_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	6	Every year to every 3 plan years	2				1	10.00	10.00	10.00	1	2	2	2	1	6	Every date of service to 3 years	2				3		0.00	20.00	1	2	2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	10.00	10.00	10.00	1	2	2	2	1	3		2				1	10.00	10.00	10.00	1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	540.00	1	2	2	1				2				3		35.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		35.00	250.00	1	2																2	1				2				3		0.00	150.00	1	2
H0562	097	0	1	01	01	H0562_097_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	6	Every year to every 3 plan years	2				1	10.00	10.00	10.00	1	2	2	2	1	6	Every date of service to 3 years	2				3		0.00	20.00	1	2	2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	10.00	10.00	10.00	1	2	2	2	1	3		2				1	10.00	10.00	10.00	1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	540.00	1	2	2	1				2				3		35.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		35.00	250.00	1	2																2	1				2				3		0.00	150.00	1	2
H0562	125	0	1	01	01	H0562_125_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	6	Every year to every 3 plan years	2				1	10.00	10.00	10.00	1	2	2	2	1	6	Every date of service to 3 years	2				3		0.00	20.00	1	2	2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	10.00	10.00	10.00	1	2	2	2	1	3		2				1	10.00	10.00	10.00	1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	540.00	1	2	2	1				2				3		35.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		35.00	250.00	1	2																2	1				2				3		0.00	150.00	1	2
H0562	126	0	1	01	01	H0562_126_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	6	Every year to every 3 plan years	2				1	10.00	10.00	10.00	1	2	2	2	1	6	Every date of service to 3 years	2				3		0.00	20.00	1	2	2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	10.00	10.00	10.00	1	2	2	2	1	3		2				1	10.00	10.00	10.00	1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	540.00	1	2	2	1				2				3		35.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		35.00	250.00	1	2																2	1				2				3		0.00	150.00	1	2
H0562	136	0	1	01	01	H0562_136_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	6	Every year to every 3 plan years	2				1	10.00	10.00	10.00	1	2	2	2	1	6	Every date of service to 3 years	2				3		0.00	20.00	1	2	2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	10.00	10.00	10.00	1	2	2	2	1	3		2				1	10.00	10.00	10.00	1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	540.00	1	2	2	1				2				3		35.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		35.00	250.00	1	2																2	1				2				3		0.00	150.00	1	2
H0562	137	0	1	01	01	H0562_137_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	6	Every year to every 3 plan years	2				1	10.00	10.00	10.00	1	2	2	2	1	6	Every date of service to 3 years	2				3		0.00	20.00	1	2	2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	10.00	10.00	10.00	1	2	2	2	1	3		2				1	10.00	10.00	10.00	1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	540.00	1	2	2	1				2				3		35.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		35.00	250.00	1	2																2	1				2				3		0.00	150.00	1	2
H0562	138	0	1	01	01	H0562_138_0	6	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	6	Every year to every 3 plan years	2				1	10.00	10.00	10.00	1	2	2	2	1	6	Every date of service to 3 years	2				3		0.00	20.00	1	2	2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	10.00	10.00	10.00	1	2	2	2	1	3		2				1	10.00	10.00	10.00	1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	540.00	1	2	2	1				2				3		35.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		35.00	250.00	1	2																2	1				2				3		0.00	150.00	1	2
H0562	801	0	1	01	01	H0562_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0562	803	0	1	01	01	H0562_803_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0562	804	0	1	01	01	H0562_804_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0571	001	0	1	01	01	H0571_001_0	6	2				2				1	20.00	20.00	20.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2																															2								2					2		3													2	2	3													2	2	4	2	2	3		2				3		0.00	55.00	2	2	3													2	2																															3													2	2	3													2	2	3													2	2	4	1				2				3		0.00	5.00	2	2
H0571	005	0	1	01	01	H0571_005_0	7	2				2				2				2		2	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0571	007	0	1	01	01	H0571_007_0	6	2				2				1	20.00	20.00	20.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2																															2								2					2		3													2	2	3													2	2	4	2	2	3		2				3		0.00	55.00	2	2	3													2	2																															3													2	2	3													2	2	3													2	2	4	1				2				3		0.00	5.00	2	2
H0571	011	0	1	01	01	H0571_011_0	8	2				2				1	20.00	20.00	20.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2																															2								2					2		3													2	2	3													2	2	4	2	2	3		2				3		0.00	55.00	2	2	3													2	2																															3													2	2	3													2	2	3													2	2	4	1				2				3		0.00	5.00	2	2
H0609	007	0	1	02	01	H0609_007_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	012	0	1	02	01	H0609_012_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	018	0	1	02	01	H0609_018_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	025	0	1	02	01	H0609_025_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	026	0	1	02	01	H0609_026_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	027	0	1	02	01	H0609_027_0	5	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	028	0	1	02	01	H0609_028_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	032	0	1	02	01	H0609_032_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	033	0	1	02	01	H0609_033_0	5	2				1	20	20	20	2				2		1	1	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	034	1	1	02	01	H0609_034_1	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	034	2	1	02	01	H0609_034_2	6	2				1	20	20	20	2				2		1	2	1		2000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	036	1	1	02	01	H0609_036_1	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	036	2	1	02	01	H0609_036_2	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	037	0	1	02	01	H0609_037_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		3250.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	038	0	1	02	01	H0609_038_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	040	0	1	02	01	H0609_040_0	4	2				1	20	20	20	2				2		1	1	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	041	0	1	02	01	H0609_041_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	042	0	1	02	01	H0609_042_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	043	0	1	02	01	H0609_043_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	044	0	1	02	01	H0609_044_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	045	0	1	02	01	H0609_045_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	046	0	1	02	01	H0609_046_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	047	0	1	02	01	H0609_047_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	048	0	1	02	01	H0609_048_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	049	0	1	02	01	H0609_049_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	050	0	1	02	01	H0609_050_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	051	0	1	02	01	H0609_051_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	052	0	1	02	01	H0609_052_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0609	054	0	1	02	01	H0609_054_0	5	2				1	20	20	20	2				2		1	2																																																																																																																		2								2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H0609	055	0	1	02	01	H0609_055_0	2	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	056	0	1	02	01	H0609_056_0	2	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	058	0	1	02	01	H0609_058_0	4	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	059	0	1	02	01	H0609_059_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	060	0	1	02	01	H0609_060_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	061	0	1	02	01	H0609_061_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	062	0	1	02	01	H0609_062_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	063	0	1	02	01	H0609_063_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	066	0	1	02	01	H0609_066_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	067	0	1	02	01	H0609_067_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	068	0	1	02	01	H0609_068_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	070	0	1	02	01	H0609_070_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	071	0	1	02	01	H0609_071_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	072	0	1	02	01	H0609_072_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	073	0	1	02	01	H0609_073_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	075	0	1	02	01	H0609_075_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	077	0	1	02	01	H0609_077_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0609	079	0	1	02	01	H0609_079_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	080	0	1	02	01	H0609_080_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	083	0	1	02	01	H0609_083_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	084	0	1	02	01	H0609_084_0	3	2				1	20	20	20	2				2		1	1	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	085	0	1	02	01	H0609_085_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	090	0	1	02	01	H0609_090_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	091	0	1	02	01	H0609_091_0	4	2				1	20	20	20	2				2		1	2	1		500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0609	801	0	1	01	01	H0609_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0609	804	0	1	01	01	H0609_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0609	805	0	1	01	01	H0609_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0609	806	0	2	01	01	H0609_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0609	807	0	1	01	01	H0609_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0609	808	0	1	01	01	H0609_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0609	809	0	1	01	01	H0609_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0609	810	0	1	01	01	H0609_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0609	811	0	1	01	01	H0609_811_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0609	812	0	1	01	01	H0609_812_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0609	813	0	1	01	01	H0609_813_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0609	814	0	1	01	01	H0609_814_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0609	815	0	1	01	01	H0609_815_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0609	817	0	1	01	01	H0609_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0609	822	0	1	01	01	H0609_822_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0609	823	0	1	01	01	H0609_823_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0609	824	0	1	01	01	H0609_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0613	001	0	1	20	08	H0613_001_0	1																																																																																																																																																																																																																																																																																																						
H0613	003	0	1	20	08	H0613_003_0	1																																																																																																																																																																																																																																																																																																						
H0624	001	0	1	02	01	H0624_001_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0624	007	0	1	02	01	H0624_007_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0624	008	1	1	02	01	H0624_008_1	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0624	008	2	1	02	01	H0624_008_2	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0628	001	0	1	02	01	H0628_001_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	003	0	1	02	01	H0628_003_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	005	0	1	02	01	H0628_005_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	007	0	1	02	01	H0628_007_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H0628	008	0	1	02	01	H0628_008_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H0628	010	0	1	02	01	H0628_010_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	012	0	1	01	01	H0628_012_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	017	0	1	02	01	H0628_017_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	018	0	1	01	01	H0628_018_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	021	0	1	02	01	H0628_021_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	024	0	1	02	01	H0628_024_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H0628	031	0	1	01	01	H0628_031_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	032	0	1	01	01	H0628_032_0	3	2				1	20	20	20	2				2		1	2	1		2250.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	033	0	1	01	01	H0628_033_0	3	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	034	0	1	01	01	H0628_034_0	3	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	036	0	1	01	01	H0628_036_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	037	0	1	01	01	H0628_037_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	038	0	1	01	01	H0628_038_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	039	0	1	01	01	H0628_039_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	040	0	1	01	01	H0628_040_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	042	0	1	01	01	H0628_042_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	043	0	1	01	01	H0628_043_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	044	0	1	01	01	H0628_044_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	045	0	1	02	01	H0628_045_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	801	0	1	01	01	H0628_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0629	001	0	1	01	01	H0629_001_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0629	002	0	1	01	01	H0629_002_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0629	003	0	1	01	01	H0629_003_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Limited to cleaning around implant when there is inflammation and limited to removing broken implant screw.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Limited to fixed applicance therapy.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0629	004	0	1	01	01	H0629_004_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Limited to cleaning around implant when there is inflammation and limited to removing broken implant screw.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Limited to fixed applicance therapy.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0630	013	0	1	02	01	H0630_013_0	9	2				2				1	25.00	25.00	25.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Radiographs subject to rolling limits: bitewings 1 per 11 months; occlusal images 2 per 12 months; panoramic and full mouth series limited to 1 per 60 months. Periapical images are unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Fluoride treatments limited to 1 per 11 rolling months.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	6	Fillings limited 1 per surface per tooth every rolling 24 months. Inlays/onlays limited 1 every rolling 60 months; crowns every rolling 84 months; prefabricated crowns every rolling 36 months. Protective restorations limited 1 per lifetime. Pin retention 1 per tooth. Recement services are unlimited.	1	50	50	50	2				2	2	2	2	1	6	Endodontic therapy limited to 1 per tooth every 24 rolling months. Pulpal debridement limited to 1 every 12 rolling months. Retreatment and other endodontic procedures limited to 1 per tooth per lifetime. Retrograde filling limited to 1 per root.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgical procedures limited to 1 every 36 rolling months. Scaling and root planing limited to 1 per quadrant every 24 rolling months. Periodontal maintenance and gingival inflammation procedures limited to 2 per calendar year.	3		0	50	2				2	2	2	2	1	6	Complete and partial dentures 1/60 rolling months. Adjustments 2/12 rolling months. Rebases and relines 1/36 rolling months. Repairs 2/lifetime; replacement of broken teeth and addition of teeth to partial dentures 1 per tooth lifetime. Tissue conditioning 2/36 rolling months per appliance.	1	50	50	50	2				2	2																3													2	2	2	2	1	6	Pontics, retainers, crowns, inlays/onlays limited to 1 every 84 rolling months. Re-cementation or re-bonding limited to 1 per lifetime. Repairs limited to 1 every 12 rolling months.	1	50	50	50	2				2	2	2	2	1	6	Extractions and surgical removals limited to 1 per tooth per lifetime. Eruption device placement limited to 1 every 12 rolling months. Tissue excision procedures limited to 1 every 36 rolling months.	1	50	50	50	2				2	2																2	2	1	6	Palliative treatment limited to 3 visits per 6 rolling months. Anesthesia and sedation services limited to 1 initial unit per day with up to 4 additional units per day.	3		0	50	2				2	2
H0630	014	0	1	01	01	H0630_014_0	9	2				2				1	10.00	10.00	10.00	2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Radiographs subject to rolling limits: bitewings 1 per 11 months; occlusal images 2 per 12 months; panoramic and full mouth series limited to 1 per 60 months. Periapical images are unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Fluoride treatments limited to 1 per 11 rolling months.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	6	Fillings limited 1 per surface per tooth every rolling 24 months. Inlays/onlays limited 1 every rolling 60 months; crowns every rolling 84 months; prefabricated crowns every rolling 36 months. Protective restorations limited 1 per lifetime. Pin retention 1 per tooth. Recement services are unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic therapy limited to 1 per tooth every 24 rolling months. Pulpal debridement limited to 1 every 12 rolling months. Retreatment and other endodontic procedures limited to 1 per tooth per lifetime. Retrograde filling limited to 1 per root.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodontal surgical procedures limited to 1 every 36 rolling months. Scaling and root planing limited to 1 per quadrant every 24 rolling months. Periodontal maintenance and gingival inflammation procedures limited to 2 per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Complete and partial dentures 1/60 rolling months. Adjustments 2/12 rolling months. Rebases and relines 1/36 rolling months. Repairs 2/lifetime; replacement of broken teeth and addition of teeth to partial dentures 1 per tooth lifetime. Tissue conditioning 2/36 rolling months per appliance.	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Pontics, retainers, crowns, inlays/onlays limited to 1 every 84 rolling months. Re-cementation or re-bonding limited to 1 per lifetime. Repairs limited to 1 every 12 rolling months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Extractions and surgical removals limited to 1 per tooth per lifetime. Eruption device placement limited to 1 every 12 rolling months. Tissue excision procedures limited to 1 every 36 rolling months.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Palliative treatment limited to 3 visits per 6 rolling months. Anesthesia and sedation services limited to 1 initial unit per day with up to 4 additional units per day.	2				1	0.00	0.00	0.00	2	2
H0630	015	0	1	02	01	H0630_015_0	8	2				2				1	20.00	20.00	20.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Radiographs subject to rolling limits: bitewings 1 per 11 months; occlusal images 2 per 12 months; panoramic and full mouth series limited to 1 per 60 months. Periapical images are unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Fluoride treatments limited to 1 per 11 rolling months.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	6	Fillings limited 1 per surface per tooth every rolling 24 months. Inlays/onlays limited 1 every rolling 60 months; crowns every rolling 84 months; prefabricated crowns every rolling 36 months. Protective restorations limited 1 per lifetime. Pin retention 1 per tooth. Recement services are unlimited.	1	50	50	50	2				2	2	2	2	1	6	Endodontic therapy limited to 1 per tooth every 24 rolling months. Pulpal debridement limited to 1 every 12 rolling months. Retreatment and other endodontic procedures limited to 1 per tooth per lifetime. Retrograde filling limited to 1 per root.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgical procedures limited to 1 every 36 rolling months. Scaling and root planing limited to 1 per quadrant every 24 rolling months. Periodontal maintenance and gingival inflammation procedures limited to 2 per calendar year.	3		0	50	2				2	2	2	2	1	6	Complete and partial dentures 1/60 rolling months. Adjustments 2/12 rolling months. Rebases and relines 1/36 rolling months. Repairs 2/lifetime; replacement of broken teeth and addition of teeth to partial dentures 1 per tooth lifetime. Tissue conditioning 2/36 rolling months per appliance.	1	50	50	50	2				2	2																3													2	2	2	2	1	6	Pontics, retainers, crowns, inlays/onlays limited to 1 every 84 rolling months. Re-cementation or re-bonding limited to 1 per lifetime. Repairs limited to 1 every 12 rolling months.	1	50	50	50	2				2	2	2	2	1	6	Extractions and surgical removals limited to 1 per tooth per lifetime. Eruption device placement limited to 1 every 12 rolling months. Tissue excision procedures limited to 1 every 36 rolling months.	1	50	50	50	2				2	2																2	2	1	6	Palliative treatment limited to 3 visits per 6 rolling months. Anesthesia and sedation services limited to 1 initial unit per day with up to 4 additional units per day.	3		0	50	2				2	2
H0630	016	0	1	02	01	H0630_016_0	8	2				2				1	15.00	15.00	15.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Radiographs subject to rolling limits: bitewings 1 per 11 months; occlusal images 2 per 12 months; panoramic and full mouth series limited to 1 per 60 months. Periapical images are unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Fluoride treatments limited to 1 per 11 rolling months.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	6	Fillings limited 1 per surface per tooth every rolling 24 months. Inlays/onlays limited 1 every rolling 60 months; crowns every rolling 84 months; prefabricated crowns every rolling 36 months. Protective restorations limited 1 per lifetime. Pin retention 1 per tooth. Recement services are unlimited.	1	50	50	50	2				2	2	2	2	1	6	Endodontic therapy limited to 1 per tooth every 24 rolling months. Pulpal debridement limited to 1 every 12 rolling months. Retreatment and other endodontic procedures limited to 1 per tooth per lifetime. Retrograde filling limited to 1 per root.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgical procedures limited to 1 every 36 rolling months. Scaling and root planing limited to 1 per quadrant every 24 rolling months. Periodontal maintenance and gingival inflammation procedures limited to 2 per calendar year.	3		0	50	2				2	2	2	2	1	6	Complete and partial dentures 1/60 rolling months. Adjustments 2/12 rolling months. Rebases and relines 1/36 rolling months. Repairs 2/lifetime; replacement of broken teeth and addition of teeth to partial dentures 1 per tooth lifetime. Tissue conditioning 2/36 rolling months per appliance.	1	50	50	50	2				2	2																3													2	2	2	2	1	6	Pontics, retainers, crowns, inlays/onlays limited to 1 every 84 rolling months. Re-cementation or re-bonding limited to 1 per lifetime. Repairs limited to 1 every 12 rolling months.	1	50	50	50	2				2	2	2	2	1	6	Extractions and surgical removals limited to 1 per tooth per lifetime. Eruption device placement limited to 1 every 12 rolling months. Tissue excision procedures limited to 1 every 36 rolling months.	1	50	50	50	2				2	2																2	2	1	6	Palliative treatment limited to 3 visits per 6 rolling months. Anesthesia and sedation services limited to 1 initial unit per day with up to 4 additional units per day.	3		0	50	2				2	2
H0630	017	0	1	02	01	H0630_017_0	8	2				2				1	40.00	40.00	40.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Radiographs subject to rolling limits: bitewings 1 per 11 months; occlusal images 2 per 12 months; panoramic and full mouth series limited to 1 per 60 months. Periapical images are unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Fluoride treatments limited to 1 per 11 rolling months.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	6	Fillings limited 1 per surface per tooth every rolling 24 months. Inlays/onlays limited 1 every rolling 60 months; crowns every rolling 84 months; prefabricated crowns every rolling 36 months. Protective restorations limited 1 per lifetime. Pin retention 1 per tooth. Recement services are unlimited.	1	50	50	50	2				2	2	2	2	1	6	Endodontic therapy limited to 1 per tooth every 24 rolling months. Pulpal debridement limited to 1 every 12 rolling months. Retreatment and other endodontic procedures limited to 1 per tooth per lifetime. Retrograde filling limited to 1 per root.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgical procedures limited to 1 every 36 rolling months. Scaling and root planing limited to 1 per quadrant every 24 rolling months. Periodontal maintenance and gingival inflammation procedures limited to 2 per calendar year.	3		0	50	2				2	2	2	2	1	6	Complete and partial dentures 1/60 rolling months. Adjustments 2/12 rolling months. Rebases and relines 1/36 rolling months. Repairs 2/lifetime; replacement of broken teeth and addition of teeth to partial dentures 1 per tooth lifetime. Tissue conditioning 2/36 rolling months per appliance.	1	50	50	50	2				2	2																3													2	2	2	2	1	6	Pontics, retainers, crowns, inlays/onlays limited to 1 every 84 rolling months. Re-cementation or re-bonding limited to 1 per lifetime. Repairs limited to 1 every 12 rolling months.	1	50	50	50	2				2	2	2	2	1	6	Extractions and surgical removals limited to 1 per tooth per lifetime. Eruption device placement limited to 1 every 12 rolling months. Tissue excision procedures limited to 1 every 36 rolling months.	1	50	50	50	2				2	2																2	2	1	6	Palliative treatment limited to 3 visits per 6 rolling months. Anesthesia and sedation services limited to 1 initial unit per day with up to 4 additional units per day.	3		0	50	2				2	2
H0630	020	0	1	02	01	H0630_020_0	8	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Radiographs subject to rolling limits: bitewings 1 per 11 months; occlusal images 2 per 12 months; panoramic and full mouth series limited to 1 per 60 months. Periapical images are unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Fluoride treatments limited to 1 per 11 rolling months.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	6	Fillings limited 1 per surface per tooth every rolling 24 months. Inlays/onlays limited 1 every rolling 60 months; crowns every rolling 84 months; prefabricated crowns every rolling 36 months. Protective restorations limited 1 per lifetime. Pin retention 1 per tooth. Recement services are unlimited.	1	50	50	50	2				2	2	2	2	1	6	Endodontic therapy limited to 1 per tooth every 24 rolling months. Pulpal debridement limited to 1 every 12 rolling months. Retreatment and other endodontic procedures limited to 1 per tooth per lifetime. Retrograde filling limited to 1 per root.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgical procedures limited to 1 every 36 rolling months. Scaling and root planing limited to 1 per quadrant every 24 rolling months. Periodontal maintenance and gingival inflammation procedures limited to 2 per calendar year.	3		0	50	2				2	2	2	2	1	6	Complete and partial dentures 1/60 rolling months. Adjustments 2/12 rolling months. Rebases and relines 1/36 rolling months. Repairs 2/lifetime; replacement of broken teeth and addition of teeth to partial dentures 1 per tooth lifetime. Tissue conditioning 2/36 rolling months per appliance.	1	50	50	50	2				2	2																3													2	2	2	2	1	6	Pontics, retainers, crowns, inlays/onlays limited to 1 every 84 rolling months. Re-cementation or re-bonding limited to 1 per lifetime. Repairs limited to 1 every 12 rolling months.	1	50	50	50	2				2	2	2	2	1	6	Extractions and surgical removals limited to 1 per tooth per lifetime. Eruption device placement limited to 1 every 12 rolling months. Tissue excision procedures limited to 1 every 36 rolling months.	1	50	50	50	2				2	2																2	2	1	6	Palliative treatment limited to 3 visits per 6 rolling months. Anesthesia and sedation services limited to 1 initial unit per day with up to 4 additional units per day.	3		0	50	2				2	2
H0630	021	0	1	02	01	H0630_021_0	8	2				2				1	25.00	25.00	25.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Radiographs subject to rolling limits: bitewings 1 per 11 months; occlusal images 2 per 12 months; panoramic and full mouth series limited to 1 per 60 months. Periapical images are unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Fluoride treatments limited to 1 per 11 rolling months.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	6	Fillings limited 1 per surface per tooth every rolling 24 months. Inlays/onlays limited 1 every rolling 60 months; crowns every rolling 84 months; prefabricated crowns every rolling 36 months. Protective restorations limited 1 per lifetime. Pin retention 1 per tooth. Recement services are unlimited.	1	50	50	50	2				2	2	2	2	1	6	Endodontic therapy limited to 1 per tooth every 24 rolling months. Pulpal debridement limited to 1 every 12 rolling months. Retreatment and other endodontic procedures limited to 1 per tooth per lifetime. Retrograde filling limited to 1 per root.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgical procedures limited to 1 every 36 rolling months. Scaling and root planing limited to 1 per quadrant every 24 rolling months. Periodontal maintenance and gingival inflammation procedures limited to 2 per calendar year.	3		0	50	2				2	2	2	2	1	6	Complete and partial dentures 1/60 rolling months. Adjustments 2/12 rolling months. Rebases and relines 1/36 rolling months. Repairs 2/lifetime; replacement of broken teeth and addition of teeth to partial dentures 1 per tooth lifetime. Tissue conditioning 2/36 rolling months per appliance.	1	50	50	50	2				2	2																3													2	2	2	2	1	6	Pontics, retainers, crowns, inlays/onlays limited to 1 every 84 rolling months. Re-cementation or re-bonding limited to 1 per lifetime. Repairs limited to 1 every 12 rolling months.	1	50	50	50	2				2	2	2	2	1	6	Extractions and surgical removals limited to 1 per tooth per lifetime. Eruption device placement limited to 1 every 12 rolling months. Tissue excision procedures limited to 1 every 36 rolling months.	1	50	50	50	2				2	2																2	2	1	6	Palliative treatment limited to 3 visits per 6 rolling months. Anesthesia and sedation services limited to 1 initial unit per day with up to 4 additional units per day.	3		0	50	2				2	2
H0630	023	0	1	02	01	H0630_023_0	8	2				2				1	35.00	35.00	35.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Radiographs subject to rolling limits: bitewings 1 per 11 months; occlusal images 2 per 12 months; panoramic and full mouth series limited to 1 per 60 months. Periapical images are unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Fluoride treatments limited to 1 per 11 rolling months.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	6	Fillings limited 1 per surface per tooth every rolling 24 months. Inlays/onlays limited 1 every rolling 60 months; crowns every rolling 84 months; prefabricated crowns every rolling 36 months. Protective restorations limited 1 per lifetime. Pin retention 1 per tooth. Recement services are unlimited.	1	50	50	50	2				2	2	2	2	1	6	Endodontic therapy limited to 1 per tooth every 24 rolling months. Pulpal debridement limited to 1 every 12 rolling months. Retreatment and other endodontic procedures limited to 1 per tooth per lifetime. Retrograde filling limited to 1 per root.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgical procedures limited to 1 every 36 rolling months. Scaling and root planing limited to 1 per quadrant every 24 rolling months. Periodontal maintenance and gingival inflammation procedures limited to 2 per calendar year.	3		0	50	2				2	2	2	2	1	6	Complete and partial dentures 1/60 rolling months. Adjustments 2/12 rolling months. Rebases and relines 1/36 rolling months. Repairs 2/lifetime; replacement of broken teeth and addition of teeth to partial dentures 1 per tooth lifetime. Tissue conditioning 2/36 rolling months per appliance.	1	50	50	50	2				2	2																3													2	2	2	2	1	6	Pontics, retainers, crowns, inlays/onlays limited to 1 every 84 rolling months. Re-cementation or re-bonding limited to 1 per lifetime. Repairs limited to 1 every 12 rolling months.	1	50	50	50	2				2	2	2	2	1	6	Extractions and surgical removals limited to 1 per tooth per lifetime. Eruption device placement limited to 1 every 12 rolling months. Tissue excision procedures limited to 1 every 36 rolling months.	1	50	50	50	2				2	2																2	2	1	6	Palliative treatment limited to 3 visits per 6 rolling months. Anesthesia and sedation services limited to 1 initial unit per day with up to 4 additional units per day.	3		0	50	2				2	2
H0630	024	0	1	01	01	H0630_024_0	8	2				1	20	20	20	2				2		2	2	1		3500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Radiographs subject to rolling limits: bitewings 1 per 11 months; occlusal images 2 per 12 months; panoramic and full mouth series limited to 1 per 60 months. Periapical images are unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Fluoride treatments limited to 1 per 11 rolling months.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	6	Fillings limited 1 per surface per tooth every rolling 24 months. Inlays/onlays limited 1 every rolling 60 months; crowns every rolling 84 months; prefabricated crowns every rolling 36 months. Protective restorations limited 1 per lifetime. Pin retention 1 per tooth. Recement services are unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic therapy limited to 1 per tooth every 24 rolling months. Pulpal debridement limited to 1 every 12 rolling months. Retreatment and other endodontic procedures limited to 1 per tooth per lifetime. Retrograde filling limited to 1 per root.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodontal surgical procedures limited to 1 every 36 rolling months. Scaling and root planing limited to 1 per quadrant every 24 rolling months. Periodontal maintenance and gingival inflammation procedures limited to 2 per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Complete and partial dentures 1/60 rolling months. Adjustments 2/12 rolling months. Rebases and relines 1/36 rolling months. Repairs 2/lifetime; replacement of broken teeth and addition of teeth to partial dentures 1 per tooth lifetime. Tissue conditioning 2/36 rolling months per appliance.	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Pontics, retainers, crowns, inlays/onlays limited to 1 every 84 rolling months. Re-cementation or re-bonding limited to 1 per lifetime. Repairs limited to 1 every 12 rolling months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Extractions and surgical removals limited to 1 per tooth per lifetime. Eruption device placement limited to 1 every 12 rolling months. Tissue excision procedures limited to 1 every 36 rolling months.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Palliative treatment limited to 3 visits per 6 rolling months. Anesthesia and sedation services limited to 1 initial unit per day with up to 4 additional units per day.	2				1	0.00	0.00	0.00	2	2
H0630	025	0	1	02	01	H0630_025_0	8	2				2				1	40.00	40.00	40.00	2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Radiographs subject to rolling limits: bitewings 1 per 11 months; occlusal images 2 per 12 months; panoramic and full mouth series limited to 1 per 60 months. Periapical images are unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Fluoride treatments limited to 1 per 11 rolling months.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	6	Fillings limited 1 per surface per tooth every rolling 24 months. Inlays/onlays limited 1 every rolling 60 months; crowns every rolling 84 months; prefabricated crowns every rolling 36 months. Protective restorations limited 1 per lifetime. Pin retention 1 per tooth. Recement services are unlimited.	1	50	50	50	2				2	2	2	2	1	6	Endodontic therapy limited to 1 per tooth every 24 rolling months. Pulpal debridement limited to 1 every 12 rolling months. Retreatment and other endodontic procedures limited to 1 per tooth per lifetime. Retrograde filling limited to 1 per root.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgical procedures limited to 1 every 36 rolling months. Scaling and root planing limited to 1 per quadrant every 24 rolling months. Periodontal maintenance and gingival inflammation procedures limited to 2 per calendar year.	3		0	50	2				2	2	2	2	1	6	Complete and partial dentures 1/60 rolling months. Adjustments 2/12 rolling months. Rebases and relines 1/36 rolling months. Repairs 2/lifetime; replacement of broken teeth and addition of teeth to partial dentures 1 per tooth lifetime. Tissue conditioning 2/36 rolling months per appliance.	1	50	50	50	2				2	2																3													2	2	2	2	1	6	Pontics, retainers, crowns, inlays/onlays limited to 1 every 84 rolling months. Re-cementation or re-bonding limited to 1 per lifetime. Repairs limited to 1 every 12 rolling months.	1	50	50	50	2				2	2	2	2	1	6	Extractions and surgical removals limited to 1 per tooth per lifetime. Eruption device placement limited to 1 every 12 rolling months. Tissue excision procedures limited to 1 every 36 rolling months.	1	50	50	50	2				2	2																2	2	1	6	Palliative treatment limited to 3 visits per 6 rolling months. Anesthesia and sedation services limited to 1 initial unit per day with up to 4 additional units per day.	3		0	50	2				2	2
H0630	027	0	1	01	01	H0630_027_0	8	2				1	20	20	20	2				2		2	2	1		3500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Radiographs subject to rolling limits: bitewings 1 per 11 months; occlusal images 2 per 12 months; panoramic and full mouth series limited to 1 per 60 months. Periapical images are unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Fluoride treatments limited to 1 per 11 rolling months.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	6	Fillings limited 1 per surface per tooth every rolling 24 months. Inlays/onlays limited 1 every rolling 60 months; crowns every rolling 84 months; prefabricated crowns every rolling 36 months. Protective restorations limited 1 per lifetime. Pin retention 1 per tooth. Recement services are unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic therapy limited to 1 per tooth every 24 rolling months. Pulpal debridement limited to 1 every 12 rolling months. Retreatment and other endodontic procedures limited to 1 per tooth per lifetime. Retrograde filling limited to 1 per root.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodontal surgical procedures limited to 1 every 36 rolling months. Scaling and root planing limited to 1 per quadrant every 24 rolling months. Periodontal maintenance and gingival inflammation procedures limited to 2 per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Complete and partial dentures 1/60 rolling months. Adjustments 2/12 rolling months. Rebases and relines 1/36 rolling months. Repairs 2/lifetime; replacement of broken teeth and addition of teeth to partial dentures 1 per tooth lifetime. Tissue conditioning 2/36 rolling months per appliance.	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Pontics, retainers, crowns, inlays/onlays limited to 1 every 84 rolling months. Re-cementation or re-bonding limited to 1 per lifetime. Repairs limited to 1 every 12 rolling months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Extractions and surgical removals limited to 1 per tooth per lifetime. Eruption device placement limited to 1 every 12 rolling months. Tissue excision procedures limited to 1 every 36 rolling months.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Palliative treatment limited to 3 visits per 6 rolling months. Anesthesia and sedation services limited to 1 initial unit per day with up to 4 additional units per day.	2				1	0.00	0.00	0.00	2	2
H0630	805	0	2	01	01	H0630_805_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0630	806	0	2	01	01	H0630_806_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0630	807	0	1	01	01	H0630_807_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0630	808	0	1	01	01	H0630_808_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0630	811	0	2	01	01	H0630_811_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0630	812	0	2	01	01	H0630_812_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0630	813	0	1	01	01	H0630_813_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0630	814	0	1	01	01	H0630_814_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0630	817	0	2	01	01	H0630_817_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0630	818	0	2	01	01	H0630_818_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0630	819	0	1	01	01	H0630_819_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0630	820	0	1	01	01	H0630_820_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H0672	005	0	1	01	01	H0672_005_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		1200.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	006	0	1	01	01	H0672_006_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H0672	013	0	1	01	01	H0672_013_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	016	0	1	01	01	H0672_016_0	7	2				2				1	40.00	40.00	40.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	017	0	1	01	01	H0672_017_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		350.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	801	0	1	01	01	H0672_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0710	004	0	1	04	01	H0710_004_0	4	2				1	20	20	20	2				2		1	2	1	2	2400.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	005	0	1	04	01	H0710_005_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0710	007	0	1	04	01	H0710_007_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0710	010	0	1	04	01	H0710_010_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0710	013	0	1	04	01	H0710_013_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	016	0	1	04	01	H0710_016_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0710	017	0	1	04	01	H0710_017_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	020	0	1	04	01	H0710_020_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0710	026	0	1	04	01	H0710_026_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0710	027	0	1	04	01	H0710_027_0	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	030	0	1	04	01	H0710_030_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	031	0	1	04	01	H0710_031_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	032	0	1	04	01	H0710_032_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	033	0	1	04	01	H0710_033_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0710	034	0	1	04	01	H0710_034_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	035	0	1	04	01	H0710_035_0	4	2				1	20	20	20	2				2		1	2	1	2	2400.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	036	0	1	04	01	H0710_036_0	4	2				1	20	20	20	2				2		1	2	1	2	2400.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	037	0	1	04	01	H0710_037_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	038	0	1	04	01	H0710_038_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0710	039	0	1	04	01	H0710_039_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	051	0	1	04	01	H0710_051_0	6	2				1	20	20	20	2				2		1	2	1	2	2400.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	052	0	1	04	01	H0710_052_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0710	053	0	1	04	01	H0710_053_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0710	057	0	1	04	01	H0710_057_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	074	0	1	04	01	H0710_074_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0710	801	0	1	04	01	H0710_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	802	0	1	04	01	H0710_802_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	803	0	1	04	01	H0710_803_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	804	0	2	04	01	H0710_804_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	805	0	2	04	01	H0710_805_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	806	0	2	04	01	H0710_806_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	807	0	1	04	01	H0710_807_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	808	0	1	04	01	H0710_808_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	809	0	1	04	01	H0710_809_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	810	0	1	04	01	H0710_810_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	811	0	1	04	01	H0710_811_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	812	0	2	04	01	H0710_812_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	813	0	2	04	01	H0710_813_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	814	0	2	04	01	H0710_814_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	815	0	1	04	01	H0710_815_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	816	0	1	04	01	H0710_816_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	817	0	1	04	01	H0710_817_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	818	0	1	04	01	H0710_818_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	819	0	1	04	01	H0710_819_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	820	0	1	04	01	H0710_820_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	821	0	1	04	01	H0710_821_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	822	0	1	04	01	H0710_822_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	823	0	1	04	01	H0710_823_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	824	0	2	04	01	H0710_824_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	825	0	1	04	01	H0710_825_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	826	0	1	04	01	H0710_826_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	827	0	1	04	01	H0710_827_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	829	0	1	04	01	H0710_829_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	830	0	1	04	01	H0710_830_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0710	831	0	1	04	01	H0710_831_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0712	005	0	1	02	01	H0712_005_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H0712	019	0	1	02	01	H0712_019_0	6	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H0712	029	0	1	01	01	H0712_029_0	6	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0724	801	0	1	01	01	H0724_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0725	001	0	1	20	08	H0725_001_0	4																																																																																																																																																																																																																																																																																																						
H0725	002	0	1	20	08	H0725_002_0	4																																																																																																																																																																																																																																																																																																						
H0738	001	0	1	01	01	H0738_001_0	6	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Pre and post-op radiographs required. Prior authorization required. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 months. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H0738	002	0	1	01	01	H0738_002_0	9	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		1250.00	3		2		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Pre and post-op radiographs required. Prior authorization required. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 months. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year.  Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H0755	030	0	1	02	01	H0755_030_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0755	031	0	1	02	01	H0755_031_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0755	032	0	1	02	01	H0755_032_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0755	033	0	1	02	01	H0755_033_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0755	037	0	1	02	01	H0755_037_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0755	038	0	1	02	01	H0755_038_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0755	044	0	1	02	01	H0755_044_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0755	045	0	1	02	01	H0755_045_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0755	046	0	1	02	01	H0755_046_0	4	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H0755	047	0	1	02	01	H0755_047_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H0755	810	0	1	01	01	H0755_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0755	811	0	1	01	01	H0755_811_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0755	812	0	1	01	01	H0755_812_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0755	813	0	1	01	01	H0755_813_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0755	814	0	1	01	01	H0755_814_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0755	815	0	1	01	01	H0755_815_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0764	001	0	1	04	01	H0764_001_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H0777	001	0	1	01	01	H0777_001_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	periodic oral eval 2 per yearlimited oral exam problem focused 2 per yearcomprehensive oral eval 1 per lifetimeComprehensive periodontal exam 1 per year	2				2				2	2	2	2	1	6	Intraoral- comprehensive series 1 per 3 yearsIntraoral periapical 4 per day and 12 per 12 monthsBitewings 2 per calendar yearpanoramic 1 per 3 yearscephalometric radiographic image (requires auth and must be used in conjunction with surgical condition)	2				2				1	2																2	2	2	3		2				2				2	2	2	2	1	5		2				2				2	2	2	2	2	6	two per tooth per lifetime	2				2				2	2	2								2					2		2	2	1	6	Amalgam 1 per year per toothResin based 1 per year per toothcrown - porcelain/ceramic 1 per 60 months recement not covered within 6months of placement	2				2				1	2	2	2	1	6	endodontics one per lifetime per toothapicoectomy one per lifetime per toothretreatment not within 24 months	2				2				2	2	2	2	1	6	periodontal scaling and root planning 1 per quadrant per 3 years scaling in presence of generalized moderate or severe gingival inflammation 2 per year gingivectomy or gingivoplasty -1 per 3 years	2				2				1	2	2	2	1	6	one every eighty four months	2				2				2	2																																														2	2	1	6	one coronectomy per tooth per lifetimeone alveoloplasty per patient per quadrant per six months	2				2				1	2																2	2	2	6	Palliative treatment-2 every calendar yearConsultations-1 every 6 monthsBehavior Management 1 per day per provider or location	2				2				1	2
H0809	001	0	1	20	08	H0809_001_0	1																																																																																																																																																																																																																																																																																																						
H0809	002	0	1	20	08	H0809_002_0	1																																																																																																																																																																																																																																																																																																						
H0816	001	0	1	02	01	H0816_001_0	10	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																1	2		500.00	3		2		2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2
H0816	002	0	1	02	01	H0816_002_0	11	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																																																																																																																																																																																				
H0819	001	0	1	20	08	H0819_001_0	1																																																																																																																																																																																																																																																																																																						
H0819	002	0	1	20	08	H0819_002_0	1																																																																																																																																																																																																																																																																																																						
H0839	001	0	1	20	08	H0839_001_0	1																																																																																																																																																																																																																																																																																																						
H0839	002	0	1	20	08	H0839_002_0	1																																																																																																																																																																																																																																																																																																						
H0870	001	0	1	20	08	H0870_001_0	1																																																																																																																																																																																																																																																																																																						
H0870	002	0	1	20	08	H0870_002_0	1																																																																																																																																																																																																																																																																																																						
H0907	003	0	1	02	01	H0907_003_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0908	804	0	1	02	01	H0908_804_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0913	002	0	1	02	01	H0913_002_0	5	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H0913	013	0	1	01	01	H0913_013_0	7	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H0913	015	0	1	02	01	H0913_015_0	5	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H0934	001	0	1	20	08	H0934_001_0	1																																																																																																																																																																																																																																																																																																						
H0934	002	0	1	20	08	H0934_002_0	1																																																																																																																																																																																																																																																																																																						
H0963	001	0	1	01	01	H0963_001_0	4	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	4	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam 1/yr, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/3 yrs, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H0976	001	0	1	01	01	H0976_001_0	11	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				1	2	1	2		5000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0976	002	0	1	01	01	H0976_002_0	10	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				1	2	1	2		5000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0978	001	0	1	01	01	H0978_001_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0978	002	0	1	01	01	H0978_002_0	11	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0978	010	0	1	01	01	H0978_010_0	11	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		4000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0978	012	0	1	01	01	H0978_012_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2500.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H0978	802	0	1	01	01	H0978_802_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0978	803	0	1	01	01	H0978_803_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0978	804	0	1	01	01	H0978_804_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0978	805	0	1	01	01	H0978_805_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H0982	002	0	1	01	01	H0982_002_0	16	2				2				2				2		1	1	1		5000.00	3		2		2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				2	2																2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2																2	2	1	6	see note below	2				2				1	2
H0982	007	0	1	01	01	H0982_007_0	14	2				2				2				2		1	1	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	008	0	1	01	01	H0982_008_0	14	2				2				2				2		1	1	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	009	0	1	01	01	H0982_009_0	15	2				2				2				2		1	1	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	010	0	1	01	01	H0982_010_0	14	2				2				2				2		1	1	1		4000.00	3		2		2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				2	2																2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2																2	2	1	6	see note below	2				2				1	2
H0982	012	0	1	01	01	H0982_012_0	14	2				2				2				2		1	1	1		5000.00	3		2		2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				2	2																2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2																2	2	1	6	see note below	2				2				1	2
H0982	013	0	1	01	01	H0982_013_0	14	2				2				2				2		1	1	1		5000.00	3		2		2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				2	2																2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2																2	2	1	6	see note below	2				2				1	2
H0982	016	0	1	01	01	H0982_016_0	14	2				2				2				2		1	1	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	017	0	1	01	01	H0982_017_0	14	2				2				2				2		1	1	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	022	0	1	01	01	H0982_022_0	15	2				2				2				2		1	1	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	024	0	1	01	01	H0982_024_0	14	2				2				2				2		1	1	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	025	0	1	01	01	H0982_025_0	14	2				2				2				2		1	1	1		4000.00	3		2		2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				2	2																2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2																2	2	1	6	see note below	2				2				1	2
H0982	026	0	1	01	01	H0982_026_0	14	2				2				2				2		1	1	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	027	0	1	01	01	H0982_027_0	15	2				2				2				2		1	1	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	028	0	1	01	01	H0982_028_0	14	2				2				2				2		1	1	2							2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2																																2	2	1	6	see note below	2				2				1	2																																																																																																									
H0982	030	0	1	01	01	H0982_030_0	14	2				2				2				2		1	1	2							2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2																																2	2	1	6	see note below	2				2				1	2																																																																																																									
H0982	031	0	1	01	01	H0982_031_0	14	2				2				2				2		1	1	2							2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2																																2	2	1	6	see note below	2				2				1	2																																																																																																									
H0982	033	0	1	01	01	H0982_033_0	14	2				2				2				2		1	1	2							2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2																																2	2	1	6	see note below	2				2				1	2																																																																																																									
H0982	034	0	1	01	01	H0982_034_0	14	2				2				2				2		1	1	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1019	001	0	1	02	01	H1019_001_0	6	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	6	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	006	0	1	01	01	H1019_006_0	6	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	6	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions for dentures unl/yr, extractions 6/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	023	0	1	01	01	H1019_023_0	4	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	6	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	043	0	1	02	01	H1019_043_0	5	2				2				1	15.00	15.00	15.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																2	2	2	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions for dentures unl/yr, extractions 3/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	057	0	1	02	01	H1019_057_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	6	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	065	0	1	01	01	H1019_065_0	5	2				2				1	20.00	20.00	20.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	1	3		2				1	0.00	0.00	0.00	1	1																																																																																											2	2	1	3		2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	073	0	1	01	01	H1019_073_0	4	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					2					2		2	2	3	6	comp oral exam 1/3 yrs, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	5	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	3		2				1	0.00	0.00	0.00	1	1	2	2	1	6	complete or partial dentures 1/5 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	6	6	extractions for dentures unl/yr, extractions 6/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	094	0	1	01	01	H1019_094_0	5	2				2				1	30.00	30.00	30.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	1	3		2				1	0.00	0.00	0.00	1	1																																																																																											2	2	1	3		2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	103	1	1	02	01	H1019_103_1	6	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																2	2	2	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions for dentures unl/yr, extractions 3/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	103	2	1	02	01	H1019_103_2	6	2				2				1	5.00	5.00	5.00	2		1	1	2							2				2					2					2		2	2	3	6	comp oral exam 1/3 yrs, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	1																															2	2	2	6	comp dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions for dentures unl/yr, extractions 3/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	104	1	1	01	01	H1019_104_1	5	2				2				1	20.00	20.00	20.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	6	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	104	2	1	01	01	H1019_104_2	5	2				2				1	20.00	20.00	20.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		1	0	0	0	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	109	0	1	01	01	H1019_109_0	5	2				2				1	20.00	20.00	20.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	6	3		3		0	30	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	2	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	6	6	extractions for dentures unl/yr, extractions 6/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	113	0	1	01	01	H1019_113_0	5	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	6	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	118	0	1	01	01	H1019_118_0	6	2				2				1	20.00	20.00	20.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	6	3		3		0	30	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	2	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	6	6	extractions for dentures unl/yr, extractions 6/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	121	0	1	01	01	H1019_121_0	5	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	6	3		3		0	30	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	2	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	6	6	extractions for dentures unl/yr, extractions 6/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	123	0	1	01	01	H1019_123_0	5	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		1	0	0	0	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	124	0	1	02	01	H1019_124_0	6	2				2				1	20.00	20.00	20.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		1	0	0	0	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	130	0	1	02	01	H1019_130_0	7	2				2				1	20.00	20.00	20.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		1	0	0	0	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	132	0	1	01	01	H1019_132_0	4	2				2				1	30.00	30.00	30.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																2	2	6	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions for dentures unl/yr, extractions 3/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	134	0	1	01	01	H1019_134_0	4	2				2				1	20.00	20.00	20.00	2		1	1	2							2				2					2					2		2	2	3	6	comp oral exam 1/3 yrs, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	2	3		1	0	0	0	2				1	1																2	2	4	3		1	0	0	0	2				1	1	2	2	1	6	part/comp dentures 1/5 yrs	1	30	30	30	2				1	1																																														2	2	2	6	extractions for dentures unl/yr, extractions 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	135	0	1	02	01	H1019_135_0	6	2				2				1	25.00	25.00	25.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	5	3		3		0	30	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	136	0	1	01	01	H1019_136_0	5	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		2	2	3	6	comp oral exam 1/3 yrs, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	1																															2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions for dentures unl/yr, extractions 3/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	138	0	1	01	01	H1019_138_0	5	2				2				1	20.00	20.00	20.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	5	3		3		0	30	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		0	30	2				1	1	2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	139	0	1	01	01	H1019_139_0	4	2				2				1	35.00	35.00	35.00	2		1	1	2							2				2					2					2		2	2	3	6	comp oral exam 1/3 yrs, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	2	3		1	0	0	0	2				1	1																2	2	4	3		1	0	0	0	2				1	1	2	2	1	6	part/comp dentures 1/5 yrs	1	30	30	30	2				1	1																																														2	2	2	6	extractions for dentures unl/yr, extractions 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	144	0	1	01	01	H1019_144_0	4	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																																																													2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1019	146	0	1	01	01	H1019_146_0	4	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					2					2		2	2	3	6	comp oral exam 1/3 yrs, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	1																															2	2	2	6	comp dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions for dentures unl/yr, extractions 3/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	147	1	1	01	01	H1019_147_1	6	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	5	3		3		0	30	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		0	30	2				1	1	2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	147	2	1	01	01	H1019_147_2	5	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	2	3		1	0	0	0	2				1	1																2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	148	0	1	01	01	H1019_148_0	5	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1019	149	0	1	01	01	H1019_149_0	5	2				2				1	15.00	15.00	15.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	5	3		3		0	30	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	150	0	1	01	01	H1019_150_0	5	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		1	0	0	0	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		0	30	2				1	1	2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	151	1	1	01	01	H1019_151_1	6	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	5	3		3		0	30	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		0	30	2				1	1	2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	151	2	1	01	01	H1019_151_2	5	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	2	3		1	0	0	0	2				1	1																2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		0	30	2				1	1	2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	153	0	1	01	01	H1019_153_0	4	2				1	20	20	20	2				2		1	1	2							2				2					2					2		2	2	3	6	comp oral exam 1/3 yrs, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	6	part/comp dentures 1/5 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	2	6	extractions for dentures unl/yr, extractions 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	154	0	1	01	01	H1019_154_0	5	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		1	0	0	0	2				1	1	2	2	1	3		1	0	0	0	2				1	1	2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1019	155	0	1	02	01	H1019_155_0	4	2				2				1	30.00	30.00	30.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	6	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	156	0	1	01	01	H1019_156_0	4	2				2				1	20.00	20.00	20.00	2		1	1	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2								2					2		2	2	2	3		1	0	0	0	2				1	1																2	2	6	3		1	0	0	0	2				1	1	2	2	2	6	complete or partial dentures 1/5 yrs, denture adjustments, rebase, reline 1/yr	1	30	30	30	2				1	1																																														2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	1	0	0	0	2				1	1																2	1				1	0	0	0	2				1	1
H1032	193	0	1	02	01	H1032_193_0	11	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1032	194	0	1	02	01	H1032_194_0	10	2				2				1	5.00	5.00	5.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth Every 7 plan years. Other restorative Every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per plan year, and once per same tooth Every 7 plan years; other implant services Every year to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth Every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	195	0	1	02	01	H1032_195_0	10	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	196	0	1	02	01	H1032_196_0	10	2				2				1	5.00	5.00	5.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth Every 7 plan years. Other restorative Every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per plan year, and once per same tooth Every 7 plan years; other implant services Every year to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth Every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	198	0	1	02	01	H1032_198_0	10	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1032	199	0	1	02	01	H1032_199_0	9	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	200	0	1	02	01	H1032_200_0	10	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1032	201	0	1	02	01	H1032_201_0	10	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth Every 7 plan years. Other restorative Every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per plan year, and once per same tooth Every 7 plan years; other implant services Every year to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth Every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	202	0	1	02	01	H1032_202_0	10	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	204	0	1	02	01	H1032_204_0	10	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1032	205	0	1	02	01	H1032_205_0	10	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	210	0	1	02	01	H1032_210_0	10	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1032	211	0	1	02	01	H1032_211_0	10	2				2				1	5.00	5.00	5.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth Every 7 plan years. Other restorative Every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per plan year, and once per same tooth Every 7 plan years; other implant services Every year to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth Every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	212	0	1	02	01	H1032_212_0	10	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1032	213	0	1	02	01	H1032_213_0	9	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth Every 7 plan years. Other restorative Every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per plan year, and once per same tooth Every 7 plan years; other implant services Every year to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth Every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	246	0	1	01	01	H1032_246_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	247	0	1	01	01	H1032_247_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	248	0	1	02	01	H1032_248_0	10	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	249	0	1	02	01	H1032_249_0	9	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1032	250	0	1	01	01	H1032_250_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth Every 7 plan years. Other restorative Every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per plan year, and once per same tooth Every 7 plan years; other implant services Every year to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth Every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1035	002	0	1	01	01	H1035_002_0	9	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	017	0	1	01	01	H1035_017_0	12	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	019	0	1	01	01	H1035_019_0	12	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	020	0	1	01	01	H1035_020_0	12	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	021	0	1	01	01	H1035_021_0	10	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	022	0	1	01	01	H1035_022_0	12	2				2				1	10.00	10.00	10.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1035	025	0	1	01	01	H1035_025_0	12	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	4	6	Fillings: Limited to two per year.Crowns: Limited to one per year when performed in conjunction with an eligible root canal procedure. Crown Supporting:  Limited to one per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	Scaling and Root Planing: up to 4 quadrants total per 36 month period, limited to one procedure per quadrant.Full Mouth Debridement: limited to once per 36 month period.	2				1	0.00	0.00	0.00	2	2	2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H1035	026	0	1	01	01	H1035_026_0	12	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	4	6	Fillings: Limited to two per year.Crowns: Limited to one per year when performed in conjunction with an eligible root canal procedure. Crown Supporting:  Limited to one per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	Scaling and Root Planing: up to 4 quadrants total per 36 month period, limited to one procedure per quadrant.Full Mouth Debridement: limited to once per 36 month period.	2				1	0.00	0.00	0.00	2	2	2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H1035	033	0	1	01	01	H1035_033_0	12	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	4	6	Fillings: Limited to two per year.Crowns: Limited to one per year when performed in conjunction with an eligible root canal procedure. Crown Supporting:  Limited to one per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	Scaling and Root Planing: up to 4 quadrants total per 36 month period, limited to one procedure per quadrant.Full Mouth Debridement: limited to once per 36 month period.	2				1	0.00	0.00	0.00	2	2	2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H1035	034	0	1	01	01	H1035_034_0	12	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	4	6	Fillings: Limited to two per year.Crowns: Limited to one per year when performed in conjunction with an eligible root canal procedure. Crown Supporting:  Limited to one per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	Scaling and Root Planing: up to 4 quadrants total per 36 month period, limited to one procedure per quadrant.Full Mouth Debridement: limited to once per 36 month period.	2				1	0.00	0.00	0.00	2	2	2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H1035	040	0	1	01	01	H1035_040_0	9	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	043	0	1	01	01	H1035_043_0	14	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1035	045	0	1	01	01	H1035_045_0	12	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2		2				2					2	000000				2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1035	048	0	1	01	01	H1035_048_0	12	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	4	6	Fillings: Limited to two per year.Crowns: Limited to one per year when performed in conjunction with an eligible root canal procedure. Crown Supporting:  Limited to one per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	Scaling and Root Planing: up to 4 quadrants total per 36 month period, limited to one procedure per quadrant.Full Mouth Debridement: limited to once per 36 month period.	2				1	0.00	0.00	0.00	2	2	2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H1035	052	0	1	01	01	H1035_052_0	10	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1035	055	0	1	01	01	H1035_055_0	10	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1035	056	0	1	01	01	H1035_056_0	10	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1035	057	0	1	01	01	H1035_057_0	9	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1035	059	0	1	01	01	H1035_059_0	9	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	060	0	1	01	01	H1035_060_0	9	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	801	0	1	01	01	H1035_801_0	7	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1035	802	0	1	01	01	H1035_802_0	7	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1035	803	0	1	01	01	H1035_803_0	7	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1035	804	0	1	01	01	H1035_804_0	7	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1036	025	0	1	01	01	H1036_025_0	6	2				2				1	10.00	10.00	10.00	2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	044	0	1	01	01	H1036_044_0	5	2				2				1	10.00	10.00	10.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	1	6	extractions 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	054	0	1	01	01	H1036_054_0	6	2				2				1	0.00	0.00	0.00	2		1	1	1		6000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	062	0	1	01	01	H1036_062_0	5	2				2				1	5.00	5.00	5.00	2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	065	0	1	01	01	H1036_065_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	068	0	1	01	01	H1036_068_0	5	2				2				1	10.00	10.00	10.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	1	6	extractions 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	074	0	1	01	01	H1036_074_0	6	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	1	6	extractions 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	077	0	1	01	01	H1036_077_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	102	0	1	01	01	H1036_102_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	119	0	1	01	01	H1036_119_0	4	2				2				1	30.00	30.00	30.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	1	6	extractions 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	121	0	1	01	01	H1036_121_0	6	2				2				1	15.00	15.00	15.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	137	0	1	02	01	H1036_137_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1036	143	0	1	01	01	H1036_143_0	5	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	1	6	extractions 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	146	0	1	01	01	H1036_146_0	5	2				2				1	5.00	5.00	5.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	1	6	extractions 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	151	0	1	01	01	H1036_151_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1036	153	0	1	01	01	H1036_153_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	157	0	1	01	01	H1036_157_0	5	2				2				1	25.00	25.00	25.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	167	0	1	01	01	H1036_167_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	209	0	1	01	01	H1036_209_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	210	0	1	01	01	H1036_210_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	213	0	1	01	01	H1036_213_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	214	0	1	01	01	H1036_214_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	217	0	1	01	01	H1036_217_0	5	2				2				1	10.00	10.00	10.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	222	0	1	01	01	H1036_222_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	226	0	1	01	01	H1036_226_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	229	0	1	01	01	H1036_229_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H1036	230	0	1	01	01	H1036_230_0	6	2				2				1	5.00	5.00	5.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	1	6	extractions 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	233	0	1	02	01	H1036_233_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1036	234	0	1	01	01	H1036_234_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H1036	236	0	1	01	01	H1036_236_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	265	1	1	01	01	H1036_265_1	5	2				2				1	10.00	10.00	10.00	2		1	1	1		1250.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	265	2	1	01	01	H1036_265_2	6	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	1																2	2	4	3		2				1	0.00	0.00	0.00	1	1																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H1036	266	0	1	01	01	H1036_266_0	5	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	269	0	1	01	01	H1036_269_0	5	2				2				1	15.00	15.00	15.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	270	0	1	01	01	H1036_270_0	6	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	271	0	1	01	01	H1036_271_0	5	2				2				1	35.00	35.00	35.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	278	0	1	01	01	H1036_278_0	5	2				2				1	35.00	35.00	35.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	25.00	25.00	25.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				3		0.00	25.00	1	1																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H1036	279	0	1	01	01	H1036_279_0	4	2				2				1	40.00	40.00	40.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	280	0	1	01	01	H1036_280_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	285	0	1	01	01	H1036_285_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	286	0	1	01	01	H1036_286_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H1036	290	0	1	01	01	H1036_290_0	4	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	25.00	25.00	25.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				3		0.00	25.00	1	1																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H1036	292	0	1	01	01	H1036_292_0	5	2				2				1	20.00	20.00	20.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	25.00	25.00	25.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				3		0.00	25.00	1	1																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H1036	297	0	1	01	01	H1036_297_0	7	2				2				1	15.00	15.00	15.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	298	0	1	01	01	H1036_298_0	5	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	299	0	1	01	01	H1036_299_0	6	2				2				1	10.00	10.00	10.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	300	0	1	01	01	H1036_300_0	6	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	301	0	1	01	01	H1036_301_0	6	2				2				1	30.00	30.00	30.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	25.00	25.00	25.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				3		0.00	25.00	1	1																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H1036	302	0	1	01	01	H1036_302_0	6	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	304	0	1	01	01	H1036_304_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	305	0	1	01	01	H1036_305_0	5	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	1																2	2	4	3		2				1	0.00	0.00	0.00	1	1																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H1036	306	0	1	01	01	H1036_306_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1036	307	0	1	01	01	H1036_307_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	308	0	1	01	01	H1036_308_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1036	310	0	1	01	01	H1036_310_0	6	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	1																2	2	4	3		2				1	0.00	0.00	0.00	1	1																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H1036	311	0	1	01	01	H1036_311_0	6	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	1																2	2	4	3		2				1	0.00	0.00	0.00	1	1																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H1036	312	0	1	01	01	H1036_312_0	6	2				2				1	10.00	10.00	10.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	313	0	1	01	01	H1036_313_0	6	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	314	0	1	01	01	H1036_314_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	315	0	1	01	01	H1036_315_0	6	2				2				1	30.00	30.00	30.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	25.00	25.00	25.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				3		0.00	25.00	1	1																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H1036	316	0	1	01	01	H1036_316_0	6	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	317	0	1	01	01	H1036_317_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	0.00	0.00	0.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H1036	318	0	1	02	01	H1036_318_0	5	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H1036	319	0	1	01	01	H1036_319_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H1036	321	0	1	01	01	H1036_321_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H1036	322	0	1	01	01	H1036_322_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1036	323	0	1	01	01	H1036_323_0	6	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H1036	325	0	1	01	01	H1036_325_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	327	0	1	01	01	H1036_327_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1036	328	0	1	01	01	H1036_328_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	329	0	1	01	01	H1036_329_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	330	0	1	01	01	H1036_330_0	4	2				2				1	5.00	5.00	5.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1036	331	0	1	01	01	H1036_331_0	4	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	332	0	1	01	01	H1036_332_0	6	2				2				1	30.00	30.00	30.00	2		1	1	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	333	0	1	01	01	H1036_333_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1036	334	0	1	01	01	H1036_334_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H1036	335	1	1	02	01	H1036_335_1	5	2				2				1	5.00	5.00	5.00	2		1	2	1		4000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1036	335	2	1	02	01	H1036_335_2	5	2				2				1	10.00	10.00	10.00	2		1	2	1		4000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1036	336	0	1	01	01	H1036_336_0	6	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	1	6	extractions 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	337	0	1	01	01	H1036_337_0	4	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	338	0	1	01	01	H1036_338_0	6	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																																														2	2	1	6	extractions 1/tooth/lifetime	1	30	30	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	339	0	1	01	01	H1036_339_0	4	2				1	20	20	20	2				2		1	1	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	340	0	1	01	01	H1036_340_0	4	2				1	20	20	20	2				2		1	1	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	341	0	1	01	01	H1036_341_0	4	2				1	20	20	20	2				2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	342	0	1	01	01	H1036_342_0	4	2				2				1	20.00	20.00	20.00	2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	343	0	1	02	01	H1036_343_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H1036	344	0	1	01	01	H1036_344_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1036	801	0	1	01	01	H1036_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1036	806	0	1	01	01	H1036_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1036	810	0	1	01	01	H1036_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1036	811	0	1	01	01	H1036_811_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1036	814	0	1	01	01	H1036_814_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1036	815	0	1	01	01	H1036_815_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1036	816	0	1	01	01	H1036_816_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1036	817	0	1	01	01	H1036_817_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1043	001	0	1	20	08	H1043_001_0	1																																																																																																																																																																																																																																																																																																						
H1043	002	0	1	20	08	H1043_002_0	1																																																																																																																																																																																																																																																																																																						
H1045	001	0	1	01	01	H1045_001_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	2	2																																														2	1				2				1	0.00	0.00	0.00	2	2																														
H1045	005	0	1	01	01	H1045_005_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	2	2																																														2	1				2				1	0.00	0.00	0.00	2	2																														
H1045	012	0	1	01	01	H1045_012_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H1045	018	0	1	01	01	H1045_018_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	2	2																																														2	1				2				1	0.00	0.00	0.00	2	2																														
H1045	025	0	1	02	01	H1045_025_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1045	026	0	1	02	01	H1045_026_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	028	0	1	02	01	H1045_028_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1045	030	0	1	02	01	H1045_030_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	031	0	1	02	01	H1045_031_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	033	0	1	02	01	H1045_033_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	034	0	1	02	01	H1045_034_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	036	0	1	02	01	H1045_036_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	037	0	1	01	01	H1045_037_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	2	2																																														2	1				2				1	0.00	0.00	0.00	2	2																														
H1045	038	0	1	01	01	H1045_038_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	2	2																																														2	1				2				1	0.00	0.00	0.00	2	2																														
H1045	039	0	1	02	01	H1045_039_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1750.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1045	041	0	1	02	01	H1045_041_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	042	0	1	02	01	H1045_042_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1045	043	0	1	02	01	H1045_043_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1045	045	0	1	02	01	H1045_045_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1045	048	1	1	02	01	H1045_048_1	6	2				1	20	20	20	2				2		1	2	1		2000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1045	048	2	1	02	01	H1045_048_2	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	048	3	1	02	01	H1045_048_3	5	2				1	20	20	20	2				2		1	2	1		1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1045	055	0	1	02	01	H1045_055_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	056	0	1	02	01	H1045_056_0	5	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1045	059	0	1	02	01	H1045_059_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1045	061	0	1	01	01	H1045_061_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	2	2																																														2	1				2				1	0.00	0.00	0.00	2	2																														
H1045	063	0	1	02	01	H1045_063_0	4	2				1	20	20	20	2				2		1	2	1		4500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1045	065	0	1	02	01	H1045_065_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1045	067	0	1	02	01	H1045_067_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	069	0	1	02	01	H1045_069_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	071	0	1	02	01	H1045_071_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1045	073	0	1	02	01	H1045_073_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1045	801	0	1	01	01	H1045_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1045	802	0	1	01	01	H1045_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1045	803	0	1	01	01	H1045_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1045	804	0	2	01	01	H1045_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1099	001	0	1	02	01	H1099_001_0	7	2				2				1	20.00	20.00	20.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H1099	006	0	1	01	01	H1099_006_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		750.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H1099	009	0	1	01	01	H1099_009_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 - 36 months, depending on the procedure.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	1 palliative treatment every 12 months. 1 consultation every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1099	014	0	1	01	01	H1099_014_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 - 36 months, depending on the procedure.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	1 palliative treatment every 12 months. 1 consultation every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1099	016	0	1	01	01	H1099_016_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 to 36 months, depending on the procedure.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	1 palliative treatment every 12 months. 1 consultation every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1099	026	0	1	01	01	H1099_026_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 - 36 months, depending on the procedure.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2																2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2																																																													2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2																2	2	1	6	1 palliative treatment every 12 months. 1 consultation every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1099	028	0	1	01	01	H1099_028_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 - 36 months, depending on the procedure.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2																2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2																																																													2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2																2	2	1	6	1 palliative treatment every 12 months. 1 consultation every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1109	005	0	1	01	01	H1109_005_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1109	801	0	1	01	01	H1109_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1109	802	0	1	01	01	H1109_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1109	805	0	1	01	01	H1109_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1112	006	0	1	02	01	H1112_006_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1112	033	0	1	02	01	H1112_033_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1112	034	0	1	02	01	H1112_034_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1112	038	0	1	02	01	H1112_038_0	5	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1112	039	0	1	02	01	H1112_039_0	5	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1112	042	0	1	02	01	H1112_042_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1112	043	0	1	02	01	H1112_043_0	5	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1112	044	0	1	02	01	H1112_044_0	5	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1112	046	0	1	02	01	H1112_046_0	6	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1112	047	0	1	02	01	H1112_047_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1112	048	0	1	02	01	H1112_048_0	6	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1112	049	0	1	02	01	H1112_049_0	5	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1119	001	0	1	01	01	H1119_001_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1170	002	0	1	01	01	H1170_002_0	6	2				2				1	25.00	25.00	25.00	2		2	2	2							2				2					2					2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2				1	0.00	0.00	0.00	2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	2		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	1	3		2				1	0.00	0.00	0.00	2	1	2								2					2		4	2	2	6	2 fillings per yr and 1 per surface per tooth every 2 yrs. 2 crowns/onlays per yr and 1 per tooth every 5 yrs. Recementation, pin retention, and prefabricated crowns limited to 1 per tooth every 2 yrs. Core buildup every 5 yrs. Restorations limited to 1 per tooth per lifetime.	2				3		0.00	464.00	2	1	4	2	2	6	2 root canals per yr and 1 per tooth per lifetime. Retreatment 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation 1 per tooth per lifetime.	2				3		22.00	625.00	2	1	4	2	2	6	2 periodontal maintenance procedures per yr. Scaling and root planing limited to 1 per quadrant every 2 yrs. Surgical procedures limited to 1 per quadrant every 3 yrs. Crown lengthening 1 per tooth lifetime. Tissue regeneration every 3 yrs. Debridement every 2 yrs.	2				3		0.00	643.00	2	1	4	2	1	6	Full, partial, and interim dentures limited to 1 every 5 yrs. Adjustments, relines, and soft liners up to 2 per yr. Repairs and additions limited to 1 per yr. Rebases every 2 yrs. Tissue conditioning 1 per yr.	2				3		25.00	738.00	2	1																3													2	2	2	2	1	6	Pontics, retainer inlays or onlays, and retainer crowns limited to 1 per tooth every 5 yrs. Recementation and repairs limited to 1 per tooth every 2 yrs. Stress breakers limited to 1 every 5 yrs.	2				3		44.00	528.00	2	1	4	2	3	6	3 extractions per yr and 1 extraction per tooth per lifetime. Reimplantation, exposure, and mobilization 1 per tooth per lifetime. Biopsies and cyst removal 1 per day. Brush biopsy 1 per yr. Alveoloplasty per quadrant and vestibuloplasty per arch 1 per lifetime. Graft 1 per site lifetime.	2				3		0.00	490.00	2	1																4	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services are governed by time-based allowances. Nitrous and sedation limited to 3 per yr; after-hours office visits 1 per yr; occlusal adjustments every 5 yrs; consults once per provider.	2				3		0.00	151.00	2	1
H1170	008	0	1	01	01	H1170_008_0	6	2				2				1	10.00	10.00	10.00	2		2	2	2							2				2					2					2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2				1	0.00	0.00	0.00	2	1	2	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	2		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	1	3		2				1	0.00	0.00	0.00	2	1	2								2					2		2	2	2	6	2 fillings per yr and 1 per surface per tooth every 2 yrs. 2 crowns/onlays per yr and 1 per tooth every 5 yrs. Recementation, pin retention, and prefabricated crowns limited to 1 per tooth every 2 yrs. Core buildup every 5 yrs. Restorations limited to 1 per tooth per lifetime.	2				1	0.00	0.00	0.00	2	1	2	2	2	6	2 root canals per yr and 1 per tooth per lifetime. Retreatment 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation 1 per tooth per lifetime.	2				1	0.00	0.00	0.00	2	1	2	2	2	6	2 periodontal maintenance procedures per yr. Scaling and root planing limited to 1 per quadrant every 2 yrs. Surgical procedures limited to 1 per quadrant every 3 yrs. Crown lengthening 1 per tooth lifetime. Tissue regeneration every 3 yrs. Debridement every 2 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	6	Full, partial, and interim dentures limited to 1 every 5 yrs. Adjustments, relines, and soft liners up to 2 per yr. Repairs and additions limited to 1 per yr. Rebases every 2 yrs. Tissue conditioning 1 per yr.	2				1	0.00	0.00	0.00	2	1																															2	2	1	6	Pontics, retainer inlays or onlays, and retainer crowns limited to 1 per tooth every 5 yrs. Recementation and repairs limited to 1 per tooth every 2 yrs. Stress breakers limited to 1 every 5 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	3	6	3 extractions per yr and 1 extraction per tooth per lifetime. Reimplantation, exposure, and mobilization 1 per tooth per lifetime. Biopsies and cyst removal 1 per day. Brush biopsy 1 per yr. Alveoloplasty per quadrant and vestibuloplasty per arch 1 per lifetime. Graft 1 per site lifetime.	2				1	0.00	0.00	0.00	2	1																2	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services are governed by time-based allowances. Nitrous and sedation limited to 3 per yr; after-hours office visits 1 per yr; occlusal adjustments every 5 yrs; consults once per provider.	2				1	0.00	0.00	0.00	2	1
H1170	009	0	1	01	01	H1170_009_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2				1	0.00	0.00	0.00	2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	2		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	1	3		2				1	0.00	0.00	0.00	2	1	2								2					2		4	2	2	6	2 fillings per yr and 1 per surface per tooth every 2 yrs. 2 crowns/onlays per yr and 1 per tooth every 5 yrs. Recementation, pin retention, and prefabricated crowns limited to 1 per tooth every 2 yrs. Core buildup every 5 yrs. Restorations limited to 1 per tooth per lifetime.	2				3		0.00	464.00	2	1	4	2	2	6	2 root canals per yr and 1 per tooth per lifetime. Retreatment 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation 1 per tooth per lifetime.	2				3		22.00	625.00	2	1	4	2	2	6	2 periodontal maintenance procedures per yr. Scaling and root planing limited to 1 per quadrant every 2 yrs. Surgical procedures limited to 1 per quadrant every 3 yrs. Crown lengthening 1 per tooth lifetime. Tissue regeneration every 3 yrs. Debridement every 2 yrs.	2				3		0.00	643.00	2	1	4	2	1	6	Full, partial, and interim dentures limited to 1 every 5 yrs. Adjustments, relines, and soft liners up to 2 per yr. Repairs and additions limited to 1 per yr. Rebases every 2 yrs. Tissue conditioning 1 per yr.	2				3		25.00	738.00	2	1																3													2	2	2	2	1	6	Pontics, retainer inlays or onlays, and retainer crowns limited to 1 per tooth every 5 yrs. Recementation and repairs limited to 1 per tooth every 2 yrs. Stress breakers limited to 1 every 5 yrs.	2				3		44.00	528.00	2	1	4	2	3	6	3 extractions per yr and 1 extraction per tooth per lifetime. Reimplantation, exposure, and mobilization 1 per tooth per lifetime. Biopsies and cyst removal 1 per day. Brush biopsy 1 per yr. Alveoloplasty per quadrant and vestibuloplasty per arch 1 per lifetime. Graft 1 per site lifetime.	2				3		0.00	490.00	2	1																4	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services are governed by time-based allowances. Nitrous and sedation limited to 3 per yr; after-hours office visits 1 per yr; occlusal adjustments every 5 yrs; consults once per provider.	2				3		0.00	151.00	2	1
H1170	011	0	1	01	01	H1170_011_0	6	2				2				1	10.00	10.00	10.00	2		2	2	2							2				2					2					2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2				1	0.00	0.00	0.00	2	1	2	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	2		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	1	3		2				1	0.00	0.00	0.00	2	1	2								2					2		2	2	2	6	2 fillings per yr and 1 per surface per tooth every 2 yrs. 2 crowns/onlays per yr and 1 per tooth every 5 yrs. Recementation, pin retention, and prefabricated crowns limited to 1 per tooth every 2 yrs. Core buildup every 5 yrs. Restorations limited to 1 per tooth per lifetime.	2				1	0.00	0.00	0.00	2	1	2	2	2	6	2 root canals per yr and 1 per tooth per lifetime. Retreatment 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation 1 per tooth per lifetime.	2				1	0.00	0.00	0.00	2	1	2	2	2	6	2 periodontal maintenance procedures per yr. Scaling and root planing limited to 1 per quadrant every 2 yrs. Surgical procedures limited to 1 per quadrant every 3 yrs. Crown lengthening 1 per tooth lifetime. Tissue regeneration every 3 yrs. Debridement every 2 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	6	Full, partial, and interim dentures limited to 1 every 5 yrs. Adjustments, relines, and soft liners up to 2 per yr. Repairs and additions limited to 1 per yr. Rebases every 2 yrs. Tissue conditioning 1 per yr.	2				1	0.00	0.00	0.00	2	1																															2	2	1	6	Pontics, retainer inlays or onlays, and retainer crowns limited to 1 per tooth every 5 yrs. Recementation and repairs limited to 1 per tooth every 2 yrs. Stress breakers limited to 1 every 5 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	3	6	3 extractions per yr and 1 extraction per tooth per lifetime. Reimplantation, exposure, and mobilization 1 per tooth per lifetime. Biopsies and cyst removal 1 per day. Brush biopsy 1 per yr. Alveoloplasty per quadrant and vestibuloplasty per arch 1 per lifetime. Graft 1 per site lifetime.	2				1	0.00	0.00	0.00	2	1																2	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services are governed by time-based allowances. Nitrous and sedation limited to 3 per yr; after-hours office visits 1 per yr; occlusal adjustments every 5 yrs; consults once per provider.	2				1	0.00	0.00	0.00	2	1
H1170	012	0	1	01	01	H1170_012_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2				1	0.00	0.00	0.00	2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	2		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	1	3		2				1	0.00	0.00	0.00	2	1	2								2					2		4	2	2	6	2 fillings per yr and 1 per surface per tooth every 2 yrs. 2 crowns/onlays per yr and 1 per tooth every 5 yrs. Recementation, pin retention, and prefabricated crowns limited to 1 per tooth every 2 yrs. Core buildup every 5 yrs. Restorations limited to 1 per tooth per lifetime.	2				3		0.00	464.00	2	1	4	2	2	6	2 root canals per yr and 1 per tooth per lifetime. Retreatment 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation 1 per tooth per lifetime.	2				3		22.00	625.00	2	1	4	2	2	6	2 periodontal maintenance procedures per yr. Scaling and root planing limited to 1 per quadrant every 2 yrs. Surgical procedures limited to 1 per quadrant every 3 yrs. Crown lengthening 1 per tooth lifetime. Tissue regeneration every 3 yrs. Debridement every 2 yrs.	2				3		0.00	643.00	2	1	4	2	1	6	Full, partial, and interim dentures limited to 1 every 5 yrs. Adjustments, relines, and soft liners up to 2 per yr. Repairs and additions limited to 1 per yr. Rebases every 2 yrs. Tissue conditioning 1 per yr.	2				3		25.00	738.00	2	1																3													2	2	2	2	1	6	Pontics, retainer inlays or onlays, and retainer crowns limited to 1 per tooth every 5 yrs. Recementation and repairs limited to 1 per tooth every 2 yrs. Stress breakers limited to 1 every 5 yrs.	2				3		44.00	528.00	2	1	4	2	3	6	3 extractions per yr and 1 extraction per tooth per lifetime. Reimplantation, exposure, and mobilization 1 per tooth per lifetime. Biopsies and cyst removal 1 per day. Brush biopsy 1 per yr. Alveoloplasty per quadrant and vestibuloplasty per arch 1 per lifetime. Graft 1 per site lifetime.	2				3		0.00	490.00	2	1																4	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services are governed by time-based allowances. Nitrous and sedation limited to 3 per yr; after-hours office visits 1 per yr; occlusal adjustments every 5 yrs; consults once per provider.	2				3		0.00	151.00	2	1
H1170	013	0	1	02	01	H1170_013_0	6	2				2				1	45.00	45.00	45.00	2		2	2	2							2				2					2					2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2				1	0.00	0.00	0.00	2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	2		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	1	3		2				1	0.00	0.00	0.00	2	1	2								2					2		4	2	2	6	2 fillings per yr and 1 per surface per tooth every 2 yrs. 2 crowns/onlays per yr and 1 per tooth every 5 yrs. Recementation, pin retention, and prefabricated crowns limited to 1 per tooth every 2 yrs. Core buildup every 5 yrs. Restorations limited to 1 per tooth per lifetime.	2				3		0.00	464.00	2	1	4	2	2	6	2 root canals per yr and 1 per tooth per lifetime. Retreatment 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation 1 per tooth per lifetime.	2				3		22.00	625.00	2	1	4	2	2	6	2 periodontal maintenance procedures per yr. Scaling and root planing limited to 1 per quadrant every 2 yrs. Surgical procedures limited to 1 per quadrant every 3 yrs. Crown lengthening 1 per tooth lifetime. Tissue regeneration every 3 yrs. Debridement every 2 yrs.	2				3		0.00	643.00	2	1	4	2	1	6	Full, partial, and interim dentures limited to 1 every 5 yrs. Adjustments, relines, and soft liners up to 2 per yr. Repairs and additions limited to 1 per yr. Rebases every 2 yrs. Tissue conditioning 1 per yr.	2				3		25.00	738.00	2	1																3													2	2	2	2	1	6	Pontics, retainer inlays or onlays, and retainer crowns limited to 1 per tooth every 5 yrs. Recementation and repairs limited to 1 per tooth every 2 yrs. Stress breakers limited to 1 every 5 yrs.	2				3		44.00	528.00	2	1	4	2	3	6	3 extractions per yr and 1 extraction per tooth per lifetime. Reimplantation, exposure, and mobilization 1 per tooth per lifetime. Biopsies and cyst removal 1 per day. Brush biopsy 1 per yr. Alveoloplasty per quadrant and vestibuloplasty per arch 1 per lifetime. Graft 1 per site lifetime.	2				3		0.00	490.00	2	1																4	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services are governed by time-based allowances. Nitrous and sedation limited to 3 per yr; after-hours office visits 1 per yr; occlusal adjustments every 5 yrs; consults once per provider.	2				3		0.00	151.00	2	1
H1170	014	0	1	01	01	H1170_014_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2				1	0.00	0.00	0.00	2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	2		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	1	3		2				1	0.00	0.00	0.00	2	1	2								2					2		4	2	2	6	2 fillings per yr and 1 per surface per tooth every 2 yrs. 2 crowns/onlays per yr and 1 per tooth every 5 yrs. Recementation, pin retention, and prefabricated crowns limited to 1 per tooth every 2 yrs. Core buildup every 5 yrs. Restorations limited to 1 per tooth per lifetime.	2				3		0.00	464.00	2	1	4	2	2	6	2 root canals per yr and 1 per tooth per lifetime. Retreatment 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation 1 per tooth per lifetime.	2				3		22.00	625.00	2	1	4	2	2	6	2 periodontal maintenance procedures per yr. Scaling and root planing limited to 1 per quadrant every 2 yrs. Surgical procedures limited to 1 per quadrant every 3 yrs. Crown lengthening 1 per tooth lifetime. Tissue regeneration every 3 yrs. Debridement every 2 yrs.	2				3		0.00	643.00	2	1	4	2	1	6	Full, partial, and interim dentures limited to 1 every 5 yrs. Adjustments, relines, and soft liners up to 2 per yr. Repairs and additions limited to 1 per yr. Rebases every 2 yrs. Tissue conditioning 1 per yr.	2				3		25.00	738.00	2	1																3													2	2	2	2	1	6	Pontics, retainer inlays or onlays, and retainer crowns limited to 1 per tooth every 5 yrs. Recementation and repairs limited to 1 per tooth every 2 yrs. Stress breakers limited to 1 every 5 yrs.	2				3		44.00	528.00	2	1	4	2	3	6	3 extractions per yr and 1 extraction per tooth per lifetime. Reimplantation, exposure, and mobilization 1 per tooth per lifetime. Biopsies and cyst removal 1 per day. Brush biopsy 1 per yr. Alveoloplasty per quadrant and vestibuloplasty per arch 1 per lifetime. Graft 1 per site lifetime.	2				3		0.00	490.00	2	1																4	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services are governed by time-based allowances. Nitrous and sedation limited to 3 per yr; after-hours office visits 1 per yr; occlusal adjustments every 5 yrs; consults once per provider.	2				3		0.00	151.00	2	1
H1170	015	0	1	01	01	H1170_015_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2				1	0.00	0.00	0.00	2	1	2	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	2		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	1	3		2				1	0.00	0.00	0.00	2	1	2								2					2		2	2	2	6	2 fillings per yr and 1 per surface per tooth every 2 yrs. 2 crowns/onlays per yr and 1 per tooth every 5 yrs. Recementation, pin retention, and prefabricated crowns limited to 1 per tooth every 2 yrs. Core buildup every 5 yrs. Restorations limited to 1 per tooth per lifetime.	2				1	0.00	0.00	0.00	2	1	2	2	2	6	2 root canals per yr and 1 per tooth per lifetime. Retreatment 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation 1 per tooth per lifetime.	2				1	0.00	0.00	0.00	2	1	2	2	2	6	2 periodontal maintenance procedures per yr. Scaling and root planing limited to 1 per quadrant every 2 yrs. Surgical procedures limited to 1 per quadrant every 3 yrs. Crown lengthening 1 per tooth lifetime. Tissue regeneration every 3 yrs. Debridement every 2 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	6	Full, partial, and interim dentures limited to 1 every 5 yrs. Adjustments, relines, and soft liners up to 2 per yr. Repairs and additions limited to 1 per yr. Rebases every 2 yrs. Tissue conditioning 1 per yr.	2				1	0.00	0.00	0.00	2	1																															2	2	1	6	Pontics, retainer inlays or onlays, and retainer crowns limited to 1 per tooth every 5 yrs. Recementation and repairs limited to 1 per tooth every 2 yrs. Stress breakers limited to 1 every 5 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	3	6	3 extractions per yr and 1 extraction per tooth per lifetime. Reimplantation, exposure, and mobilization 1 per tooth per lifetime. Biopsies and cyst removal 1 per day. Brush biopsy 1 per yr. Alveoloplasty per quadrant and vestibuloplasty per arch 1 per lifetime. Graft 1 per site lifetime.	2				1	0.00	0.00	0.00	2	1																2	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services are governed by time-based allowances. Nitrous and sedation limited to 3 per yr; after-hours office visits 1 per yr; occlusal adjustments every 5 yrs; consults once per provider.	2				1	0.00	0.00	0.00	2	1
H1170	016	0	1	01	01	H1170_016_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2				1	0.00	0.00	0.00	2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	2		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	1	3		2				1	0.00	0.00	0.00	2	1	2								2					2		4	2	2	6	2 fillings per yr and 1 per surface per tooth every 2 yrs. 2 crowns/onlays per yr and 1 per tooth every 5 yrs. Recementation, pin retention, and prefabricated crowns limited to 1 per tooth every 2 yrs. Core buildup every 5 yrs. Restorations limited to 1 per tooth per lifetime.	2				3		0.00	464.00	2	1	4	2	2	6	2 root canals per yr and 1 per tooth per lifetime. Retreatment 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation 1 per tooth per lifetime.	2				3		22.00	625.00	2	1	4	2	2	6	2 periodontal maintenance procedures per yr. Scaling and root planing limited to 1 per quadrant every 2 yrs. Surgical procedures limited to 1 per quadrant every 3 yrs. Crown lengthening 1 per tooth lifetime. Tissue regeneration every 3 yrs. Debridement every 2 yrs.	2				3		0.00	643.00	2	1	4	2	1	6	Full, partial, and interim dentures limited to 1 every 5 yrs. Adjustments, relines, and soft liners up to 2 per yr. Repairs and additions limited to 1 per yr. Rebases every 2 yrs. Tissue conditioning 1 per yr.	2				3		25.00	738.00	2	1																3													2	2	2	2	1	6	Pontics, retainer inlays or onlays, and retainer crowns limited to 1 per tooth every 5 yrs. Recementation and repairs limited to 1 per tooth every 2 yrs. Stress breakers limited to 1 every 5 yrs.	2				3		44.00	528.00	2	1	4	2	3	6	3 extractions per yr and 1 extraction per tooth per lifetime. Reimplantation, exposure, and mobilization 1 per tooth per lifetime. Biopsies and cyst removal 1 per day. Brush biopsy 1 per yr. Alveoloplasty per quadrant and vestibuloplasty per arch 1 per lifetime. Graft 1 per site lifetime.	2				3		0.00	490.00	2	1																4	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services are governed by time-based allowances. Nitrous and sedation limited to 3 per yr; after-hours office visits 1 per yr; occlusal adjustments every 5 yrs; consults once per provider.	2				3		0.00	151.00	2	1
H1170	017	0	1	01	01	H1170_017_0	5	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		2	2	2	6	Combined limit of 2 oral evaluations per yr. 1 comprehensive evaluation every 3 yrs. 1 screening or assessment per yr.	2				1	0.00	0.00	0.00	2	1	4	2	1	6	1 set of bitewing X-rays and 2 periapical images per yr. 1 panoramic or full mouth series every 2 yrs. Oral/facial images every 3 yrs.	2				1	0.00	0.00	0.00	2	1	2	2	1	2		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	2	3		2				1	0.00	0.00	0.00	2	1	2	2	1	3		2				1	0.00	0.00	0.00	2	1	2								2					2		4	2	2	6	2 fillings per yr and 1 per surface per tooth every 2 yrs. 2 crowns/onlays per yr and 1 per tooth every 5 yrs. Recementation, pin retention, and prefabricated crowns limited to 1 per tooth every 2 yrs. Core buildup every 5 yrs. Restorations limited to 1 per tooth per lifetime.	2				3		0.00	464.00	2	1	4	2	2	6	2 root canals per yr and 1 per tooth per lifetime. Retreatment 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation 1 per tooth per lifetime.	2				3		22.00	625.00	2	1	4	2	2	6	2 periodontal maintenance procedures per yr. Scaling and root planing limited to 1 per quadrant every 2 yrs. Surgical procedures limited to 1 per quadrant every 3 yrs. Crown lengthening 1 per tooth lifetime. Tissue regeneration every 3 yrs. Debridement every 2 yrs.	2				3		0.00	643.00	2	1	4	2	1	6	Full, partial, and interim dentures limited to 1 every 5 yrs. Adjustments, relines, and soft liners up to 2 per yr. Repairs and additions limited to 1 per yr. Rebases every 2 yrs. Tissue conditioning 1 per yr.	2				3		25.00	738.00	2	1																3													2	2	2	2	1	6	Pontics, retainer inlays or onlays, and retainer crowns limited to 1 per tooth every 5 yrs. Recementation and repairs limited to 1 per tooth every 2 yrs. Stress breakers limited to 1 every 5 yrs.	2				3		44.00	528.00	2	1	4	2	3	6	3 extractions per yr and 1 extraction per tooth per lifetime. Reimplantation, exposure, and mobilization 1 per tooth per lifetime. Biopsies and cyst removal 1 per day. Brush biopsy 1 per yr. Alveoloplasty per quadrant and vestibuloplasty per arch 1 per lifetime. Graft 1 per site lifetime.	2				3		0.00	490.00	2	1																4	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services are governed by time-based allowances. Nitrous and sedation limited to 3 per yr; after-hours office visits 1 per yr; occlusal adjustments every 5 yrs; consults once per provider.	2				3		0.00	151.00	2	1
H1170	801	0	1	01	01	H1170_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1170	802	0	1	01	01	H1170_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1181	001	0		07	02	H1181_001_0	3																																																																																																																																																																																																																																																																																																						
H1188	001	0	1	20	08	H1188_001_0	2																																																																																																																																																																																																																																																																																																						
H1188	003	0	1	20	08	H1188_003_0	4																																																																																																																																																																																																																																																																																																						
H1206	002	0	1	02	01	H1206_002_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1206	003	0	1	02	01	H1206_003_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1206	004	0	1	01	01	H1206_004_0	3	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1206	008	0	1	02	01	H1206_008_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1206	010	0	1	01	01	H1206_010_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1206	011	0	1	01	01	H1206_011_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1206	012	0	1	01	01	H1206_012_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1206	013	0	1	01	01	H1206_013_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1206	801	0	1	01	01	H1206_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1212	001	0	1	01	01	H1212_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1212	002	0	1	01	01	H1212_002_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1212	003	0	1	02	01	H1212_003_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H1215	001	0	1	02	01	H1215_001_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1215	003	0	1	02	01	H1215_003_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1215	005	0	1	02	01	H1215_005_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1219	001	0	1	20	08	H1219_001_0	1																																																																																																																																																																																																																																																																																																						
H1219	002	0	1	20	08	H1219_002_0	1																																																																																																																																																																																																																																																																																																						
H1224	001	0	1	01	01	H1224_001_0	12	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		2	2	1	6	1 crown per tooth every 7 years.	2				2				1	2	2	2	1	6	One Pulp Cap per tooth in a lifetime. One Pulpotomy/Pupal debridement per tooth in a lifetime.	2				2				2	2	2	2	1	6	1 Bone replacement graft & 1 Deep Cleaning per site/quad every 3 calendar years. 1 Gingival flap procedure or Guided tissue regeneration per quad every 3 years. 1 Moderate scaling every calendar year.	2				2				1	2	2	2	1	6	One partial denture (flexible base or resin base) per arch every 7 years.	2				2				1	2																															2	2	1	6	Bridge (retainer crown/pontic) 1 per tooth every 7 years	2				2				1	2	2	2	1	6	One Alveoloplasty, with or without extractions per site quad in a lifetime. One Bone replacement graft for ridge preservation per site in a lifetime.	2				2				1	2																2	2	1	6	One Consultation, other than requesting dentist every year. Five units of deep sedation or intravenous conscious sedation every calendar year. One Night Guard (Occlusal Guard) every 5 calendar years.	2				2				1	2
H1225	001	0	1	01	01	H1225_001_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodic oral exams, Extensive oral exam  problem focused, Re-Evaluation  limited problem focused  two per calendar yearLimited Oral Exam  3 per calendar YearComprehensive Oral Exam or Comprehensive Periodontal Exam  One per 3 years per provider or location	2				2				2	2	2	2	1	6	Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 yearsIntraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																				
H1225	003	0	1	01	01	H1225_003_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodic oral exams, Extensive oral exam  problem focused, Re-Evaluation  limited problem focused  two per calendar yearLimited Oral Exam  3 per calendar YearComprehensive Oral Exam or Comprehensive Periodontal Exam  One per 3 years per provider or location	2				2				2	2	2	2	1	6	Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 yearsIntraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2		2					2		2	2	1	6	See notes for details	2				2				1	2	2	2	1	6	Frequency of services:  Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime Pulpotomy, pulpal debridement - once per tooth per lifetime	2				2				1	2	2	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				2				1	2	2	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				2				1	2																2	2	1	6	 Implants - one per 5 years per tooth Re-cement implants - once every 2 years after 6 months of initial placement	2				2				1	2	2	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				2				1	2	2	2	1	6	See notes for details	2				2				1	2																2	2	1	6	See notes for details	2				2				1	2
H1225	004	0	1	01	01	H1225_004_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodic oral exams, Extensive oral exam  problem focused, Re-Evaluation  limited problem focused  two per calendar yearLimited Oral Exam  3 per calendar YearComprehensive Oral Exam or Comprehensive Periodontal Exam  One per 3 years per provider or location	2				2				2	2	2	2	1	6	Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 yearsIntraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		2		2					2		2	2	1	6	See notes for details	2				2				1	2	2	2	1	6	 Root canals and retreatment, apicoectomy, retrograde filling - once per tooth per lifetime Pulpotomy, pulpal debridement - once per tooth per lifetime	2				2				1	2	2	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				2				1	2	2	2	1	6	 Complete or immediate denture - 1 every 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				2				1	2																2	2	1	6	 Implants - one every 5 years per tooth Re-cement implants - once every 2 years after 6 months of initial placement	2				2				1	2	2	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				2				1	2	2	2	1	6	See notes for details	2				2				1	2																2	2	1	6	See notes for details	2				2				1	2
H1225	006	0	1	01	01	H1225_006_0	9	2				2				2				2		2	2	1		1000.00	3		2		2				2					2					2		2	2	1	6	Periodic oral exams, Extensive oral exam  problem focused, Re-Evaluation  limited problem focused  two per calendar yearLimited Oral Exam  3 per calendar YearComprehensive Oral Exam or Comprehensive Periodontal Exam  One per 3 years per provider or location	2				2				2	2	2	2	1	6	Intraoral Tomosynthesis Periapical Radiographic Image  One per calendar yearBitewings (1-4 images) or Intraoral Tomosynthesis bitewing image -one per calendar year	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	See notes for details	2				2				1	2	2	2	1	6	Frequency of services:  Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime Pulpotomy, pulpal debridement - once per tooth per lifetime	2				2				1	2	2	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				2				1	2	2	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				2				1	2																2	2	1	6	 Implants - one per 5 years per tooth Re-cement implants - once every 2 years after 6 months of initial placement	2				2				1	2	2	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				2				1	2	2	2	1	6	See notes for details	2				2				1	2																2	2	1	6	See notes for details	2				2				1	2
H1228	001	0	1	20	08	H1228_001_0	1																																																																																																																																																																																																																																																																																																						
H1228	002	0	1	20	08	H1228_002_0	1																																																																																																																																																																																																																																																																																																						
H1230	001	0	1	01	01	H1230_001_0	7	2				2				1	35.00	35.00	35.00	2		2	1	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	3		0	30	2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	2								2					2		4	2	1	2		1	30	30	30	2				2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																3													2	2	3													2	2	3													2	2																4	1				1	30	30	30	2				2	2
H1230	003	0	1	01	01	H1230_003_0	7	2				2				1	50.00	50.00	50.00	2		2	1	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	3		0	30	2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	2								2					2		4	2	1	2		1	30	30	30	2				2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																3													2	2	3													2	2	3													2	2																4	1				1	30	30	30	2				2	2
H1230	013	0	1	01	01	H1230_013_0	7	2				2				1	35.00	35.00	35.00	2		2	1	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	3		0	30	2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	2								2					2		4	2	1	2		1	30	30	30	2				2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																3													2	2	3													2	2	3													2	2																4	1				1	30	30	30	2				2	2
H1230	014	0	1	01	01	H1230_014_0	7	2				2				1	50.00	50.00	50.00	2		2	1	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	3		0	30	2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	2								2					2		4	2	1	2		1	30	30	30	2				2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																3													2	2	3													2	2	3													2	2																4	1				1	30	30	30	2				2	2
H1230	801	0	1	01	01	H1230_801_0	5	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																						
H1230	803	0	1	01	01	H1230_803_0	6	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																						
H1230	804	0	2	01	01	H1230_804_0	6	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																						
H1234	001	0	1	20	08	H1234_001_0	2																																																																																																																																																																																																																																																																																																						
H1234	002	0	1	20	08	H1234_002_0	2																																																																																																																																																																																																																																																																																																						
H1239	001	0	1	20	08	H1239_001_0	1																																																																																																																																																																																																																																																																																																						
H1239	002	0	1	20	08	H1239_002_0	1																																																																																																																																																																																																																																																																																																						
H1248	004	0	1	04	01	H1248_004_0	8	2				2				1	0.00	0.00	0.00	2		2	2	1	2	2200.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1248	007	0	1	04	01	H1248_007_0	10	2				2				1	0.00	0.00	0.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1248	014	0	1	04	01	H1248_014_0	8	2				2				1	0.00	0.00	0.00	2		2	2	1	2	2200.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1248	801	0	1	04	01	H1248_801_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1248	802	0	1	04	01	H1248_802_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1248	803	0	1	04	01	H1248_803_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1278	003	0	1	04	01	H1278_003_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1278	010	0	1	04	01	H1278_010_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1278	015	0	1	04	01	H1278_015_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1278	016	0	1	04	01	H1278_016_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1278	018	0	1	04	01	H1278_018_0	3	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1278	020	0	1	04	01	H1278_020_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1278	024	0	1	04	01	H1278_024_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1278	027	0	1	04	01	H1278_027_0	2	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1278	801	0	1	04	01	H1278_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1280	001	0	1	01	01	H1280_001_0	8	2				2				1	25.00	25.00	25.00	2		2	2	1		2250.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H1290	001	0	1	01	01	H1290_001_0	4	2				2				1	5.00	5.00	5.00	2		1	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	2		1500.00	3		2		2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	002	0	1	01	01	H1290_002_0	5	2				2				1	5.00	5.00	5.00	2		1	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	2		1500.00	3		2		2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	003	0	1	01	01	H1290_003_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	005	0	1	01	01	H1290_005_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	013	0	1	01	01	H1290_013_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	2		1500.00	3		2		2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	014	0	1	01	01	H1290_014_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	015	0	1	01	01	H1290_015_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	018	0	1	01	01	H1290_018_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	019	0	1	01	01	H1290_019_0	5	2				2				2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	020	0	1	01	01	H1290_020_0	5	2				2				2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	021	0	1	01	01	H1290_021_0	5	2				2				1	5.00	5.00	5.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	022	0	1	01	01	H1290_022_0	5	2				2				1	5.00	5.00	5.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	023	0	1	01	01	H1290_023_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	024	0	1	01	01	H1290_024_0	5	2				2				1	5.00	5.00	5.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	025	0	1	01	01	H1290_025_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	027	0	1	01	01	H1290_027_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	029	0	1	01	01	H1290_029_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	031	0	1	01	01	H1290_031_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	032	0	1	01	01	H1290_032_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	033	0	1	01	01	H1290_033_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	034	0	1	01	01	H1290_034_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	035	0	1	01	01	H1290_035_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	036	1	1	01	01	H1290_036_1	5	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	036	2	1	01	01	H1290_036_2	5	2				2				1	15.00	15.00	15.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	037	1	1	01	01	H1290_037_1	6	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	2		1500.00	3				2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	037	2	1	01	01	H1290_037_2	6	2				2				1	5.00	5.00	5.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	037	3	1	01	01	H1290_037_3	5	2				2				2				2		1	2	1		1500.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	037	4	1	01	01	H1290_037_4	5	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	2		1500.00	3				2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	037	5	1	01	01	H1290_037_5	5	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	039	0	1	01	01	H1290_039_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	041	0	1	01	01	H1290_041_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	042	0	1	01	01	H1290_042_0	7	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	043	0	1	01	01	H1290_043_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	044	1	1	01	01	H1290_044_1	5	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	044	2	1	01	01	H1290_044_2	6	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	2		2000.00	3				2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	044	3	1	01	01	H1290_044_3	6	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	045	0	1	01	01	H1290_045_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	046	0	1	01	01	H1290_046_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	049	0	1	01	01	H1290_049_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	050	0	1	01	01	H1290_050_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	051	1	1	01	01	H1290_051_1	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	051	2	1	01	01	H1290_051_2	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	052	0	1	01	01	H1290_052_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	053	0	1	01	01	H1290_053_0	7	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	054	0	1	01	01	H1290_054_0	7	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	055	0	1	01	01	H1290_055_0	7	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	056	0	1	01	01	H1290_056_0	6	2				2				2				2		1	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	2		3500.00	3		2		2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	057	0	1	01	01	H1290_057_0	6	2				2				1	10.00	10.00	10.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	058	0	1	01	01	H1290_058_0	6	2				2				1	15.00	15.00	15.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	059	0	1	01	01	H1290_059_0	6	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	2		3500.00	3		2		2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	060	0	1	01	01	H1290_060_0	6	2				2				1	10.00	10.00	10.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	061	0	1	01	01	H1290_061_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	062	0	1	01	01	H1290_062_0	6	2				2				2				2		1	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	2		3500.00	3		2		2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	063	0	1	01	01	H1290_063_0	6	2				2				1	5.00	5.00	5.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	064	0	1	01	01	H1290_064_0	6	2				2				1	5.00	5.00	5.00	2		1	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	2		3500.00	3		2		2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	065	0	1	01	01	H1290_065_0	6	2				2				1	5.00	5.00	5.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	066	0	1	01	01	H1290_066_0	6	2				2				1	15.00	15.00	15.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	067	0	1	01	01	H1290_067_0	4	2				2				1	5.00	5.00	5.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	068	0	1	01	01	H1290_068_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	069	0	1	01	01	H1290_069_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	070	0	1	01	01	H1290_070_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	071	0	1	01	01	H1290_071_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	072	0	1	01	01	H1290_072_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	073	0	1	01	01	H1290_073_0	4	2				2				1	5.00	5.00	5.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	074	0	1	01	01	H1290_074_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	077	0	1	01	01	H1290_077_0	6	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	078	0	1	01	01	H1290_078_0	6	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	079	0	1	01	01	H1290_079_0	6	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	080	0	1	01	01	H1290_080_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	081	0	1	01	01	H1290_081_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	082	0	1	01	01	H1290_082_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	083	0	1	01	01	H1290_083_0	6	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	084	0	1	01	01	H1290_084_0	5	2				1	30	30	30	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	085	0	1	01	01	H1290_085_0	4	2				1	30	30	30	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	086	0	1	01	01	H1290_086_0	4	2				1	30	30	30	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	087	0	1	01	01	H1290_087_0	4	2				1	30	30	30	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	088	0	1	01	01	H1290_088_0	4	2				1	30	30	30	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	089	0	1	01	01	H1290_089_0	4	2				1	30	30	30	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	090	0	1	01	01	H1290_090_0	5	2				1	30	30	30	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	091	0	1	01	01	H1290_091_0	4	2				1	30	30	30	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	092	0	1	01	01	H1290_092_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	093	0	1	01	01	H1290_093_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H1290	096	0	1	01	01	H1290_096_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	098	0	1	01	01	H1290_098_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	100	0	1	01	01	H1290_100_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	101	0	1	01	01	H1290_101_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	103	0	1	01	01	H1290_103_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	104	0	1	01	01	H1290_104_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	105	0	1	01	01	H1290_105_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	106	0	1	01	01	H1290_106_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	107	0	1	01	01	H1290_107_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	108	0	1	01	01	H1290_108_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	109	0	1	01	01	H1290_109_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	110	0	1	01	01	H1290_110_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	112	0	1	01	01	H1290_112_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	113	0	1	01	01	H1290_113_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2050.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	114	0	1	01	01	H1290_114_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	115	0	1	01	01	H1290_115_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	116	0	1	01	01	H1290_116_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1290	117	0	1	01	01	H1290_117_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1302	004	0	1	04	01	H1302_004_0	2	2				1	10	10	10	2				2		2	2	1	2	500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																1	2	2	1500.00	3		2		2					2		2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1	50	50	50	2				1	2																2	2	1	6	Implants not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	2	2	1	6	Limited to one crown per year. Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1302	802	0	1	04	01	H1302_802_0	1	2				1	10	10	10	2				2		2	2																																																																																																																																																																																																																																																																																						
H1302	803	0	1	04	01	H1302_803_0	1	2				1	10	10	10	2				2		2	2																																																																																																																																																																																																																																																																																						
H1302	804	0	1	04	01	H1302_804_0	1	2				1	10	10	10	2				2		2	2																																																																																																																																																																																																																																																																																						
H1304	803	0	1	04	01	H1304_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1304	804	0	1	04	01	H1304_804_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1310	001	0	1	20	08	H1310_001_0	1																																																																																																																																																																																																																																																																																																						
H1310	003	0	1	20	08	H1310_003_0	1																																																																																																																																																																																																																																																																																																						
H1312	001	0	1	20	08	H1312_001_0	1																																																																																																																																																																																																																																																																																																						
H1312	002	0	1	20	08	H1312_002_0	1																																																																																																																																																																																																																																																																																																						
H1339	001	0	1	01	01	H1339_001_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodic oral exams, Extensive oral exam  problem focused, Re-Evaluation  limited problem focused  two per calendar yearLimited Oral Exam  3 per calendar YearComprehensive Oral Exam or Comprehensive Periodontal Exam  One per 3 years per provider or location	2				2				2	2	2	2	1	6	Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 yearsIntraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1500.00	3		2		2					2		2	2	1	6	See notes for details	2				2				1	2	2	2	1	6	 Root canals and retreatment, apicoectomy, retrograde filling - once per tooth per lifetime Pulpotomy, pulpal debridement - once per tooth per lifetime	2				2				1	2	2	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				2				1	2	2	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				2				1	2																2	2	1	6	 Implants - one per 5 years per tooth Re-cement implants - once every 2 years after 6 months of initial placement	2				2				1	2	2	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				2				1	2	2	2	1	6	See notes for details	2				2				1	2																2	2	1	6	See notes for details	2				2				1	2
H1350	006	0	1	01	01	H1350_006_0	3	2				2				1	25.00	25.00	25.00	2		2	2	1		500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																1	2		1000.00	3		2		2					2		2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1	50	50	50	2				1	2																2	2	1	6	Implants not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	2	2	1	6	Limited to one crown per year. Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1350	032	0	1	01	01	H1350_032_0	3	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																				
H1350	033	0	1	01	01	H1350_033_0	3	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																				
H1350	034	0	1	01	01	H1350_034_0	3	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																				
H1350	035	0	1	01	01	H1350_035_0	3	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																				
H1350	036	0	1	01	01	H1350_036_0	3	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																				
H1350	037	0	1	01	01	H1350_037_0	3	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																				
H1350	803	0	1	01	01	H1350_803_0	1	2				2				1	25.00	25.00	25.00	2		2	2																																																																																																																																																																																																																																																																																						
H1350	804	0	1	01	01	H1350_804_0	1	2				2				1	25.00	25.00	25.00	2		2	2																																																																																																																																																																																																																																																																																						
H1350	805	0	1	01	01	H1350_805_0	1	2				2				1	25.00	25.00	25.00	2		2	2																																																																																																																																																																																																																																																																																						
H1350	806	0	1	02	01	H1350_806_0	1	2				2				1	25.00	25.00	25.00	2		2	2																																																																																																																																																																																																																																																																																						
H1350	807	0	1	02	01	H1350_807_0	1	2				2				1	25.00	25.00	25.00	2		2	2																																																																																																																																																																																																																																																																																						
H1357	001	0	1	20	08	H1357_001_0	2																																																																																																																																																																																																																																																																																																						
H1357	002	0	1	20	08	H1357_002_0	2																																																																																																																																																																																																																																																																																																						
H1360	001	0	1	02	01	H1360_001_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1360	002	0	1	02	01	H1360_002_0	4	2				1	20	20	20	2				2		1	1	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1360	003	0	1	02	01	H1360_003_0	4	2				1	20	20	20	2				2		1	1	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1365	006	0	1	04	01	H1365_006_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	400.00	3		2		2				2					1	110100	50.00	50.00	50.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	2	2	3		2								2	2																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	1	1							2					2		2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																														
H1365	007	0	1	04	01	H1365_007_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	500.00	3		2		2				2					1	110100	50.00	50.00	50.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	2	2	3		2								2	2																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	1	1							2					2		2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																														
H1365	802	0	1	04	01	H1365_802_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1365	803	0	1	04	01	H1365_803_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1372	001	0	1	01	01	H1372_001_0	5	2				1	20	20	20	2				2		1	2	1		850.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H1372	002	0	1	01	01	H1372_002_0	5	2				1	20	20	20	2				2		1	2	1		1200.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H1372	003	0	1	01	01	H1372_003_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H1390	001	0	1	04	01	H1390_001_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1390	002	0	1	04	01	H1390_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H1390	003	0	1	04	01	H1390_003_0	4	2				1	30	30	30	2				2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1390	004	0	1	04	01	H1390_004_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1390	005	0	1	04	01	H1390_005_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1390	006	0	1	04	01	H1390_006_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H1396	001	0	1	01	01	H1396_001_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1416	009	0	1	02	01	H1416_009_0	5	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1416	026	0	1	02	01	H1416_026_0	5	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1416	044	0	1	02	01	H1416_044_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1416	065	0	1	02	01	H1416_065_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1416	068	0	1	02	01	H1416_068_0	5	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1416	072	0	1	02	01	H1416_072_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1416	081	0	1	02	01	H1416_081_0	6	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1416	084	0	1	02	01	H1416_084_0	5	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1416	085	0	1	02	01	H1416_085_0	5	2				2				3		10.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1416	086	1	1	02	01	H1416_086_1	6	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3				2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1416	086	2	1	02	01	H1416_086_2	6	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1416	087	1	1	02	01	H1416_087_1	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3				2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1416	087	2	1	02	01	H1416_087_2	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3				2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1416	087	3	1	02	01	H1416_087_3	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3				2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1423	001	0	1	02	01	H1423_001_0	4	2				2				3		0.00	30.00	2		1	2	1		1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1423	002	0	1	02	01	H1423_002_0	4	2				2				3		0.00	30.00	2		1	2	1		1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1423	004	0	1	02	01	H1423_004_0	5	2				2				3		0.00	30.00	2		1	2	1		500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H1423	005	0	1	02	01	H1423_005_0	5	2				2				3		0.00	30.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H1423	007	0	1	01	01	H1423_007_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1423	009	0	1	02	01	H1423_009_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		750.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H1468	007	0	1	01	01	H1468_007_0	4	2				2				1	25.00	25.00	25.00	2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H1468	013	0	1	01	01	H1468_013_0	5	2				2				1	10.00	10.00	10.00	2		1	1	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1468	017	0	1	01	01	H1468_017_0	4	2				2				1	10.00	10.00	10.00	2		1	1	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1468	021	0	1	01	01	H1468_021_0	4	2				2				1	35.00	35.00	35.00	2		1	1	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H1468	802	0	1	01	01	H1468_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1468	803	0	1	01	01	H1468_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1468	805	0	1	01	01	H1468_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1468	806	0	1	01	01	H1468_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1486	001	0	1	01	01	H1486_001_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1500	001	0	1	20	08	H1500_001_0	1																																																																																																																																																																																																																																																																																																						
H1500	002	0	1	20	08	H1500_002_0	1																																																																																																																																																																																																																																																																																																						
H1518	001	0	1	20	08	H1518_001_0	1																																																																																																																																																																																																																																																																																																						
H1518	002	0	1	20	08	H1518_002_0	1																																																																																																																																																																																																																																																																																																						
H1526	001	0	1	02	01	H1526_001_0	7	2				2				1	0.00	0.00	0.00	2		2	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	1 upper, 1 lower full or partial mouth denture per-5 years	1	20	20	20	2				1	2																																														2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1526	002	0	1	02	01	H1526_002_0	8	2				2				2				2		2	2	1		4000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																																																													2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1526	003	0	1	02	01	H1526_003_0	6	2				2				1	15.00	15.00	15.00	2		2	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	Limited to 1 upper, 1 lower full or partial denture per 5 years	1	20	20	20	2				1	2																																														2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1526	004	0	1	02	01	H1526_004_0	6	2				1	20	20	20	2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																																																													2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1526	009	0	1	02	01	H1526_009_0	6	2				2				1	5.00	5.00	5.00	2		2	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	1 upper, 1 lower denture per 5 years	1	20	20	20	2				1	2																																														2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1526	010	0	1	02	01	H1526_010_0	5	2				2				1	15.00	15.00	15.00	2		2	2																																																																																																																																																																																																																																																																																						
H1526	011	0	1	02	01	H1526_011_0	5	2				2				1	15.00	15.00	15.00	2		2	2																																																																																																																																																																																																																																																																																						
H1526	012	0	1	02	01	H1526_012_0	5	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	1 upper, 1 lower partial denture per 5 years	1	20	20	20	2				1	2																																														2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1526	013	0	1	02	01	H1526_013_0	5	2				2				1	5.00	5.00	5.00	2		2	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																																																													2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1533	001	0	1	20	08	H1533_001_0	1																																																																																																																																																																																																																																																																																																						
H1533	002	0	1	20	08	H1533_002_0	1																																																																																																																																																																																																																																																																																																						
H1537	801	0	1	04	01	H1537_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	802	0	1	04	01	H1537_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	803	0	1	04	01	H1537_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	804	0	2	04	01	H1537_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	805	0	2	04	01	H1537_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	806	0	2	04	01	H1537_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	807	0	1	04	01	H1537_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	808	0	1	04	01	H1537_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	809	0	1	04	01	H1537_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	816	0	1	04	01	H1537_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	817	0	1	04	01	H1537_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	823	0	1	04	01	H1537_823_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	824	0	1	04	01	H1537_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	825	0	1	04	01	H1537_825_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	826	0	1	04	01	H1537_826_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	827	0	2	04	01	H1537_827_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	828	0	2	04	01	H1537_828_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	829	0	2	04	01	H1537_829_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	830	0	1	04	01	H1537_830_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	831	0	1	04	01	H1537_831_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	832	0	1	04	01	H1537_832_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	833	0	1	04	01	H1537_833_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	834	0	1	04	01	H1537_834_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	835	0	2	04	01	H1537_835_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	836	0	1	04	01	H1537_836_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	837	0	1	04	01	H1537_837_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	838	0	1	04	01	H1537_838_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	839	0	1	04	01	H1537_839_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	840	0	1	04	01	H1537_840_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	841	0	1	04	01	H1537_841_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	842	0	1	04	01	H1537_842_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	843	0	1	04	01	H1537_843_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	844	0	1	04	01	H1537_844_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	845	0	1	04	01	H1537_845_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	846	0	1	04	01	H1537_846_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	847	0	1	04	01	H1537_847_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	848	0	1	04	01	H1537_848_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	849	0	1	04	01	H1537_849_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	850	0	1	04	01	H1537_850_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	851	0	1	04	01	H1537_851_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	852	0	1	04	01	H1537_852_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	853	0	1	04	01	H1537_853_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	854	0	1	04	01	H1537_854_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	855	0	1	04	01	H1537_855_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	856	0	1	04	01	H1537_856_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	857	0	1	04	01	H1537_857_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	858	0	1	04	01	H1537_858_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	859	0	1	04	01	H1537_859_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	860	0	1	04	01	H1537_860_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	861	0	1	04	01	H1537_861_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	862	0	1	04	01	H1537_862_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	863	0	1	04	01	H1537_863_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	864	0	1	04	01	H1537_864_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	865	0	1	04	01	H1537_865_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	866	0	1	04	01	H1537_866_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	867	0	1	04	01	H1537_867_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	868	0	1	04	01	H1537_868_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	869	0	1	04	01	H1537_869_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	870	0	1	04	01	H1537_870_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	871	0	1	04	01	H1537_871_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	872	0	1	04	01	H1537_872_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	873	0	1	04	01	H1537_873_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	874	0	1	04	01	H1537_874_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	875	0	1	04	01	H1537_875_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1537	876	0	1	04	01	H1537_876_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1544	001	0	1	20	08	H1544_001_0	1																																																																																																																																																																																																																																																																																																						
H1544	002	0	1	20	08	H1544_002_0	1																																																																																																																																																																																																																																																																																																						
H1587	001	0	1	01	01	H1587_001_0	9	2				1	20	20	20	2				2		2	2	1		1500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H1587	003	0	1	02	01	H1587_003_0	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1607	012	0	1	04	01	H1607_012_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1800.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H1607	015	0	1	04	01	H1607_015_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H1607	809	0	1	04	01	H1607_809_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1607	811	0	1	04	01	H1607_811_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1607	812	0	1	04	01	H1607_812_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1607	813	0	1	04	01	H1607_813_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1607	815	0	1	04	01	H1607_815_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1607	816	0	1	04	01	H1607_816_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1607	817	0	2	04	01	H1607_817_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1607	819	0	2	04	01	H1607_819_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1607	820	0	2	04	01	H1607_820_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1608	001	0	1	04	01	H1608_001_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H1608	012	0	1	04	01	H1608_012_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	013	0	1	04	01	H1608_013_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	016	0	1	04	01	H1608_016_0	4	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	017	0	1	04	01	H1608_017_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	018	0	1	04	01	H1608_018_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	021	0	1	04	01	H1608_021_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	024	0	1	04	01	H1608_024_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	027	0	1	04	01	H1608_027_0	5	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	029	0	1	04	01	H1608_029_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	031	0	1	04	01	H1608_031_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H1608	038	0	1	04	01	H1608_038_0	6	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H1608	040	0	1	04	01	H1608_040_0	5	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H1608	050	0	1	04	01	H1608_050_0	4	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H1608	051	0	1	04	01	H1608_051_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	054	0	1	04	01	H1608_054_0	4	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	3000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	061	0	1	04	01	H1608_061_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1608	062	0	1	04	01	H1608_062_0	5	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1608	067	0	1	04	01	H1608_067_0	4	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H1608	072	0	1	04	01	H1608_072_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	074	0	1	04	01	H1608_074_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	079	0	1	04	01	H1608_079_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	081	0	1	04	01	H1608_081_0	6	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	085	0	1	04	01	H1608_085_0	4	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	117	0	1	04	01	H1608_117_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	118	0	1	04	01	H1608_118_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1608	119	0	1	04	01	H1608_119_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	120	0	1	04	01	H1608_120_0	5	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	121	0	1	04	01	H1608_121_0	4	2				1	20	20	20	2				2		1	2	1	2	1900.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1608	801	0	1	04	01	H1608_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1609	001	0	1	02	01	H1609_001_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1609	018	0	1	01	01	H1609_018_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	020	0	1	01	01	H1609_020_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	021	0	1	01	01	H1609_021_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	025	0	1	01	01	H1609_025_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	027	0	1	01	01	H1609_027_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	028	0	1	02	01	H1609_028_0	4	2				2				1	38.00	38.00	38.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	041	0	1	01	01	H1609_041_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	043	0	1	01	01	H1609_043_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	044	0	1	01	01	H1609_044_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	045	0	1	01	01	H1609_045_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	046	0	1	01	01	H1609_046_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	047	0	1	01	01	H1609_047_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	048	0	1	01	01	H1609_048_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	055	0	1	01	01	H1609_055_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	056	0	1	01	01	H1609_056_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	058	0	1	02	01	H1609_058_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1609	059	0	1	01	01	H1609_059_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	062	0	1	01	01	H1609_062_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	063	0	1	01	01	H1609_063_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	064	0	1	01	01	H1609_064_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	068	0	1	02	01	H1609_068_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1609	069	0	1	02	01	H1609_069_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1609	073	0	1	01	01	H1609_073_0	5	2				1	30	30	30	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	074	0	1	01	01	H1609_074_0	4	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	075	0	1	01	01	H1609_075_0	4	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	077	0	1	01	01	H1609_077_0	4	2				1	30	30	30	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	078	0	1	01	01	H1609_078_0	4	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	079	0	1	01	01	H1609_079_0	4	2				1	30	30	30	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	080	0	1	01	01	H1609_080_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	081	0	1	01	01	H1609_081_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	082	0	1	01	01	H1609_082_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	084	0	1	01	01	H1609_084_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	085	0	1	01	01	H1609_085_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	086	0	1	01	01	H1609_086_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	087	0	1	01	01	H1609_087_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	088	0	1	01	01	H1609_088_0	4	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	089	0	1	01	01	H1609_089_0	4	2				1	30	30	30	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	090	0	1	01	01	H1609_090_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	092	0	1	01	01	H1609_092_0	4	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	093	0	1	01	01	H1609_093_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	094	0	1	01	01	H1609_094_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	098	0	1	01	01	H1609_098_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	099	0	1	01	01	H1609_099_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	100	0	1	01	01	H1609_100_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	101	0	1	01	01	H1609_101_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	102	0	1	01	01	H1609_102_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	103	0	1	01	01	H1609_103_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	104	0	1	01	01	H1609_104_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	105	0	1	01	01	H1609_105_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	801	0	1	01	01	H1609_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1609	807	0	1	01	01	H1609_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1609	810	0	1	01	01	H1609_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1610	001	0	1	01	01	H1610_001_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1611	001	0	1	01	01	H1611_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1619	001	0	1	04	01	H1619_001_0	11	2				2				1	25.00	25.00	25.00	2		2	2	1	2	3000.00	3		2		2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H1619	004	0	1	04	01	H1619_004_0	12	2				2				1	20.00	20.00	20.00	2		2	2	1	2	1450.00	3		2		2				2					2					2		2	2	3	3		2				2				2	2	2	2	3	3		2				2				2	2	2	2	3	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	3	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H1622	001	0	1	20	08	H1622_001_0	1																																																																																																																																																																																																																																																																																																						
H1622	003	0	1	20	08	H1622_003_0	1																																																																																																																																																																																																																																																																																																						
H1644	001	0	1	01	01	H1644_001_0	6	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1651	001	0	1	18	06	H1651_001_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H1651	002	0	1	18	06	H1651_002_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H1651	003	0	1	18	06	H1651_003_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H1651	004	0	1	18	06	H1651_004_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H1651	005	0	1	18	06	H1651_005_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H1651	008	0	1	18	06	H1651_008_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H1651	009	0	1	18	06	H1651_009_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H1651	013	0	1	18	06	H1651_013_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H1651	015	0	1	18	06	H1651_015_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H1659	002	0	1	04	01	H1659_002_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1664	001	0	1	02	01	H1664_001_0	5	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1664	005	0	1	02	01	H1664_005_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1664	012	0	1	02	01	H1664_012_0	5	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1666	801	0	1	04	01	H1666_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1666	803	0	1	04	01	H1666_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1666	805	0	1	04	01	H1666_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1671	001	0	1	01	01	H1671_001_0	11	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1692	002	0	1	01	01	H1692_002_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1692	003	0	1	01	01	H1692_003_0	3	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1692	005	0	1	01	01	H1692_005_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1692	006	0	1	01	01	H1692_006_0	3	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1692	007	0	1	01	01	H1692_007_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1692	010	0	1	01	01	H1692_010_0	3	2				1	20	20	20	2				2		1	2	1		750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1692	011	0	1	01	01	H1692_011_0	3	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1692	801	0	1	01	01	H1692_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1693	002	0	1	20	08	H1693_002_0	1																																																																																																																																																																																																																																																																																																						
H1693	003	0	1	20	08	H1693_003_0	1																																																																																																																																																																																																																																																																																																						
H1714	001	0	1	20	08	H1714_001_0	1																																																																																																																																																																																																																																																																																																						
H1714	002	0	1	20	08	H1714_002_0	1																																																																																																																																																																																																																																																																																																						
H1722	002	0	1	01	01	H1722_002_0	9	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2
H1742	001	0	1	20	08	H1742_001_0	1																																																																																																																																																																																																																																																																																																						
H1742	002	0	1	20	08	H1742_002_0	1																																																																																																																																																																																																																																																																																																						
H1787	001	0	1	01	01	H1787_001_0	10	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1787	002	0	1	01	01	H1787_002_0	10	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	2		2000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	2	1	6	Implants are covered once per tooth per five-year period.	2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every 2 years. Bridges are covered with a $500 limit once in a five year period.	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1799	003	1	1	01	01	H1799_003_1	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H1799	003	2	1	01	01	H1799_003_2	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3600.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H1799	003	3	1	01	01	H1799_003_3	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H1822	001	0	1	01	01	H1822_001_0	12	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2		2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																															2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H1822	002	0	1	01	01	H1822_002_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1822	005	0	1	02	01	H1822_005_0	10	2				2				2				2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1822	007	0	1	01	01	H1822_007_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1500.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1822	008	0	1	02	01	H1822_008_0	10	2				1	20	20	20	2				2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1822	009	0	1	01	01	H1822_009_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H1822	010	0	1	01	01	H1822_010_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		4000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1822	011	0	1	02	01	H1822_011_0	10	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1822	801	0	1	01	01	H1822_801_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1822	802	0	1	01	01	H1822_802_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1822	803	0	1	01	01	H1822_803_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1822	804	0	1	01	01	H1822_804_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1823	001	0	1	04	01	H1823_001_0	11	2				2				3		0.00	30.00	2		2	2	1	2	2800.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1823	002	0	1	04	01	H1823_002_0	11	2				1	20	20	20	2				2		2	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1823	003	0	1	04	01	H1823_003_0	11	2				1	20	20	20	2				2		2	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1846	007	0	1	04	01	H1846_007_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H1846	804	0	1	04	01	H1846_804_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1846	805	0	1	04	01	H1846_805_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1862	003	0	1	02	01	H1862_003_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1862	004	0	1	02	01	H1862_004_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1862	005	0	1	02	01	H1862_005_0	5	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1862	006	0	1	02	01	H1862_006_0	7	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1889	002	1	1	04	01	H1889_002_1	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	002	2	1	04	01	H1889_002_2	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	005	0	1	04	01	H1889_005_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	007	0	1	04	01	H1889_007_0	4	2				1	30	30	30	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	008	0	1	04	01	H1889_008_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	009	0	1	04	01	H1889_009_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	010	0	1	04	01	H1889_010_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	012	0	1	04	01	H1889_012_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	013	0	1	04	01	H1889_013_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1889	014	0	1	04	01	H1889_014_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1889	015	0	1	04	01	H1889_015_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1889	019	0	1	04	01	H1889_019_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1889	020	0	1	04	01	H1889_020_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1889	022	0	1	04	01	H1889_022_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1889	025	0	1	04	01	H1889_025_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1889	026	0	1	04	01	H1889_026_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	028	0	1	04	01	H1889_028_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1889	030	0	1	04	01	H1889_030_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	031	0	1	04	01	H1889_031_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	034	0	1	04	01	H1889_034_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1889	035	0	1	04	01	H1889_035_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	043	0	1	04	01	H1889_043_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1889	044	1	1	04	01	H1889_044_1	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	044	2	1	04	01	H1889_044_2	4	2				1	20	20	20	2				2		1	2	1	2	5000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	045	1	1	04	01	H1889_045_1	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	045	2	1	04	01	H1889_045_2	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1889	801	0	1	04	01	H1889_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1904	001	0	1	20	08	H1904_001_0	1																																																																																																																																																																																																																																																																																																						
H1904	002	0	1	20	08	H1904_002_0	1																																																																																																																																																																																																																																																																																																						
H1914	001	0	1	04	01	H1914_001_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H1914	007	0	1	04	01	H1914_007_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1914	008	0	1	04	01	H1914_008_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1914	009	0	1	04	01	H1914_009_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1500.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1914	011	0	1	04	01	H1914_011_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H1917	001	0	1	20	08	H1917_001_0	1																																																																																																																																																																																																																																																																																																						
H1917	002	0	1	20	08	H1917_002_0	1																																																																																																																																																																																																																																																																																																						
H1947	003	0	1	01	01	H1947_003_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1947	004	0	1	01	01	H1947_004_0	4	2				1	20	20	20	2				2		1	2	1		2750.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1951	013	0	1	01	01	H1951_013_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H1951	024	0	1	01	01	H1951_024_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H1951	028	0	1	01	01	H1951_028_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1951	032	0	1	01	01	H1951_032_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1951	038	0	1	01	01	H1951_038_0	7	2				2				1	10.00	10.00	10.00	2		1	2	1		6000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1951	039	0	1	01	01	H1951_039_0	7	2				2				1	10.00	10.00	10.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1951	041	0	1	01	01	H1951_041_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1951	044	0	1	01	01	H1951_044_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		6000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1951	047	1	1	01	01	H1951_047_1	6	2				2				1	30.00	30.00	30.00	2		1	2	1		6000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1951	047	2	1	01	01	H1951_047_2	6	2				2				1	25.00	25.00	25.00	2		1	2	1		6000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1951	048	1	1	01	01	H1951_048_1	6	2				2				1	40.00	40.00	40.00	2		1	2	1		6000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1951	048	2	1	01	01	H1951_048_2	6	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H1951	049	1	1	01	01	H1951_049_1	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H1951	049	2	1	01	01	H1951_049_2	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1951	049	3	1	01	01	H1951_049_3	6	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1951	051	0	1	01	01	H1951_051_0	6	2				2				1	5.00	5.00	5.00	2		1	2	1		6000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1951	052	0	1	01	01	H1951_052_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H1951	053	0	1	01	01	H1951_053_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H1951	056	0	1	01	01	H1951_056_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1951	057	0	1	01	01	H1951_057_0	5	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1951	059	0	1	01	01	H1951_059_0	6	2				2				1	10.00	10.00	10.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1951	060	0	1	01	01	H1951_060_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H1951	061	0	1	01	01	H1951_061_0	6	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1951	062	0	1	01	01	H1951_062_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H1951	801	0	1	01	01	H1951_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1951	804	0	1	01	01	H1951_804_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1951	807	0	1	01	01	H1951_807_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1951	808	0	1	01	01	H1951_808_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H1961	014	1	1	02	01	H1961_014_1	7	2				2				1	20.00	20.00	20.00	2		1	2	1		4000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1961	014	2	1	02	01	H1961_014_2	7	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1961	014	3	1	02	01	H1961_014_3	5	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1961	017	0	1	02	01	H1961_017_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		1250.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1961	020	0	1	02	01	H1961_020_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1961	022	0	1	02	01	H1961_022_0	7	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1961	023	0	1	02	01	H1961_023_0	7	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1961	026	0	1	02	01	H1961_026_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1961	028	0	1	02	01	H1961_028_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1961	029	1	1	02	01	H1961_029_1	5	2				1	20	20	20	2				2		1	2	1		2000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1961	029	2	1	02	01	H1961_029_2	5	2				1	20	20	20	2				2		1	2	1		1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1961	030	1	1	02	01	H1961_030_1	5	2				1	20	20	20	2				2		1	2	1		3000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1961	030	2	1	02	01	H1961_030_2	5	2				1	20	20	20	2				2		1	2	1		3000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1961	031	1	1	02	01	H1961_031_1	5	2				1	20	20	20	2				2		1	2	1		2000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1961	031	2	1	02	01	H1961_031_2	5	2				1	20	20	20	2				2		1	2	1		1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H1961	032	1	1	02	01	H1961_032_1	5	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1961	032	2	1	02	01	H1961_032_2	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H1961	033	1	1	02	01	H1961_033_1	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1961	033	2	1	02	01	H1961_033_2	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H1961	801	0	1	02	01	H1961_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1961	802	0	1	02	01	H1961_802_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1961	803	0	1	01	01	H1961_803_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1961	804	0	1	01	01	H1961_804_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H1969	805	0	1	01	01	H1969_805_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1980	001	0	1	20	08	H1980_001_0	1																																																																																																																																																																																																																																																																																																						
H1980	002	0	1	20	08	H1980_002_0	1																																																																																																																																																																																																																																																																																																						
H1993	001	0	1	01	01	H1993_001_0	7	2				1	20	20	20	2				2		1	1	1		500.00	4		2		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1993	007	0	1	01	01	H1993_007_0	7	2				1	20	20	20	2				2		1	1	1		1200.00	4		2		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1993	008	0	1	01	01	H1993_008_0	7	2				1	20	20	20	2				2		1	1	1		1500.00	4		2		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1993	011	0	1	01	01	H1993_011_0	6	2				1	20	20	20	2				2		1	1	1		750.00	4		2		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1993	012	0	1	01	01	H1993_012_0	6	2				2				2				2		1	1	1		1750.00	4		2		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1993	013	0	1	01	01	H1993_013_0	8	2				1	20	20	20	2				2		1	1	1		1000.00	4		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	8	3		2				2				2	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1993	019	0	1	01	01	H1993_019_0	7	2				1	20	20	20	2				2		1	1	1		500.00	4		2		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1993	020	0	1	01	01	H1993_020_0	7	2				1	20	20	20	2				2		1	1	1		250.00	4		2		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1994	001	0	1	01	01	H1994_001_0	12	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	4		2				2				2	2	1	1							2					2		2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2
H1994	012	0	1	01	01	H1994_012_0	11	2				2				2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	1							2					2		2	1				1	20	20	20	2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2
H1994	015	0	1	01	01	H1994_015_0	8	2				1	30	30	30	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	4		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1994	016	0	1	01	01	H1994_016_0	7	2				2				1	50.00	50.00	50.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	4		2				2				2	2	1	1							2					2		2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2
H1994	017	0	1	01	01	H1994_017_0	11	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	4		2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1994	021	0	1	01	01	H1994_021_0	9	2				2				2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1994	027	0	1	01	01	H1994_027_0	12	2				2				1	35.00	35.00	35.00	2		1	2	1		3300.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1994	029	0	1	01	01	H1994_029_0	13	2				2				1	45.00	45.00	45.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1994	033	0	1	01	01	H1994_033_0	7	2				2				1	55.00	55.00	55.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1994	044	0	1	01	01	H1994_044_0	10	2				2				2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1994	045	0	1	01	01	H1994_045_0	10	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																																																																																																																																																																					
H1994	046	0	1	01	01	H1994_046_0	7	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1994	047	0	1	01	01	H1994_047_0	10	2				2				1	50.00	50.00	50.00	2		1	2																																																																																																																																																																																																																																																																																						
H1994	801	0	1	01	01	H1994_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1994	802	0	1	01	01	H1994_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1994	803	0	1	01	01	H1994_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H1997	014	0	1	01	01	H1997_014_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H2001	010	0	1	04	01	H2001_010_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	017	0	1	04	01	H2001_017_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	021	0	1	04	01	H2001_021_0	3	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	023	0	1	04	01	H2001_023_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	028	0	1	04	01	H2001_028_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	030	0	1	04	01	H2001_030_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	031	0	1	04	01	H2001_031_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	032	0	1	04	01	H2001_032_0	4	2				1	20	20	20	2				2		1	2	1	2	3500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	034	0	1	04	01	H2001_034_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	035	0	1	04	01	H2001_035_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	036	0	1	04	01	H2001_036_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	037	0	1	04	01	H2001_037_0	6	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	038	0	1	04	01	H2001_038_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	039	0	1	04	01	H2001_039_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	040	0	1	04	01	H2001_040_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	041	0	1	04	01	H2001_041_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	042	0	1	04	01	H2001_042_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	043	0	1	04	01	H2001_043_0	6	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	044	0	1	04	01	H2001_044_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	045	0	1	04	01	H2001_045_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	046	0	1	04	01	H2001_046_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	047	0	1	04	01	H2001_047_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	048	0	1	04	01	H2001_048_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	050	0	1	04	01	H2001_050_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	051	0	1	04	01	H2001_051_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	052	0	1	04	01	H2001_052_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	053	0	1	04	01	H2001_053_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	054	0	1	04	01	H2001_054_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	055	0	1	04	01	H2001_055_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	056	0	1	04	01	H2001_056_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	059	0	1	04	01	H2001_059_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	060	0	1	04	01	H2001_060_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	061	0	1	04	01	H2001_061_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	062	0	1	04	01	H2001_062_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	063	1	1	04	01	H2001_063_1	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	063	2	1	04	01	H2001_063_2	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	065	0	1	04	01	H2001_065_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	066	0	1	04	01	H2001_066_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	068	1	1	04	01	H2001_068_1	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	068	2	1	04	01	H2001_068_2	4	2				1	20	20	20	2				2		1	2						2																																																																																																																																																																																																																																																																																
H2001	069	1	1	04	01	H2001_069_1	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	069	2	1	04	01	H2001_069_2	4	2				1	20	20	20	2				2		1	2						2																																																																																																																																																																																																																																																																																
H2001	070	0	1	04	01	H2001_070_0	5	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	075	0	1	04	01	H2001_075_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	076	0	1	04	01	H2001_076_0	4	2				1	20	20	20	2				2		1	2	1	2	2250.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	077	0	1	04	01	H2001_077_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	078	0	1	04	01	H2001_078_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	079	0	1	04	01	H2001_079_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	080	0	1	04	01	H2001_080_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	081	0	1	04	01	H2001_081_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	082	0	1	04	01	H2001_082_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	085	0	1	04	01	H2001_085_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	090	0	1	04	01	H2001_090_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	094	0	1	04	01	H2001_094_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	095	0	1	04	01	H2001_095_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	096	0	1	04	01	H2001_096_0	6	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	097	0	1	04	01	H2001_097_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	098	0	1	04	01	H2001_098_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	099	0	1	04	01	H2001_099_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	102	0	1	04	01	H2001_102_0	6	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	103	0	1	04	01	H2001_103_0	2	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	104	0	1	04	01	H2001_104_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	108	0	1	04	01	H2001_108_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	109	0	1	04	01	H2001_109_0	6	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	110	0	1	04	01	H2001_110_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	116	0	1	04	01	H2001_116_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	117	0	1	04	01	H2001_117_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	118	0	1	04	01	H2001_118_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	119	0	1	04	01	H2001_119_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	124	0	1	04	01	H2001_124_0	3	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	125	0	1	04	01	H2001_125_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	126	0	1	04	01	H2001_126_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	127	0	1	04	01	H2001_127_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	128	0	1	04	01	H2001_128_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	131	0	1	04	01	H2001_131_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	133	0	1	04	01	H2001_133_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	134	0	1	04	01	H2001_134_0	4	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	135	0	1	04	01	H2001_135_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	139	0	1	04	01	H2001_139_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	140	0	1	04	01	H2001_140_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	141	0	1	04	01	H2001_141_0	5	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	142	0	1	04	01	H2001_142_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	143	0	1	04	01	H2001_143_0	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	144	0	1	04	01	H2001_144_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2001	146	0	1	04	01	H2001_146_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	147	0	1	04	01	H2001_147_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2001	148	0	1	04	01	H2001_148_0	3	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2001	153	0	1	04	01	H2001_153_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	802	0	1	04	01	H2001_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	816	0	1	04	01	H2001_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	817	0	1	04	01	H2001_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	818	0	1	04	01	H2001_818_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	819	0	2	04	01	H2001_819_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	820	0	2	04	01	H2001_820_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	821	0	2	04	01	H2001_821_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	822	0	1	04	01	H2001_822_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	823	0	1	04	01	H2001_823_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	824	0	1	04	01	H2001_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	825	0	1	04	01	H2001_825_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	826	0	1	04	01	H2001_826_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	827	0	1	04	01	H2001_827_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	828	0	1	04	01	H2001_828_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	829	0	1	04	01	H2001_829_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	830	0	1	04	01	H2001_830_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	831	0	1	04	01	H2001_831_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	832	0	2	04	01	H2001_832_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	833	0	2	04	01	H2001_833_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	834	0	2	04	01	H2001_834_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	835	0	1	04	01	H2001_835_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	836	0	1	04	01	H2001_836_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	837	0	1	04	01	H2001_837_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	838	0	1	04	01	H2001_838_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	839	0	2	04	01	H2001_839_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	840	0	1	04	01	H2001_840_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	841	0	1	04	01	H2001_841_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	842	0	1	04	01	H2001_842_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	843	0	1	04	01	H2001_843_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	844	0	1	04	01	H2001_844_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	845	0	1	04	01	H2001_845_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	846	0	1	04	01	H2001_846_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	847	0	1	04	01	H2001_847_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	848	0	1	04	01	H2001_848_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	849	0	1	04	01	H2001_849_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	850	0	1	04	01	H2001_850_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	851	0	1	04	01	H2001_851_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	852	0	1	04	01	H2001_852_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	853	0	1	04	01	H2001_853_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	854	0	1	04	01	H2001_854_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	855	0	1	04	01	H2001_855_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	856	0	1	04	01	H2001_856_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	857	0	1	04	01	H2001_857_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	858	0	1	04	01	H2001_858_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	859	0	1	04	01	H2001_859_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	860	0	1	04	01	H2001_860_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	861	0	1	04	01	H2001_861_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	862	0	1	04	01	H2001_862_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	863	0	1	04	01	H2001_863_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	864	0	1	04	01	H2001_864_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	865	0	1	04	01	H2001_865_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	866	0	1	04	01	H2001_866_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	867	0	1	04	01	H2001_867_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	868	0	1	04	01	H2001_868_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	869	0	1	04	01	H2001_869_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	870	0	1	04	01	H2001_870_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	871	0	1	04	01	H2001_871_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	872	0	1	04	01	H2001_872_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	873	0	1	04	01	H2001_873_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	874	0	1	04	01	H2001_874_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	875	0	1	04	01	H2001_875_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	876	0	1	04	01	H2001_876_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	877	0	1	04	01	H2001_877_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	878	0	1	04	01	H2001_878_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	879	0	1	04	01	H2001_879_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	880	0	1	04	01	H2001_880_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	881	0	1	04	01	H2001_881_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	882	0	1	04	01	H2001_882_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	883	0	1	04	01	H2001_883_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	884	0	1	04	01	H2001_884_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	886	0	1	04	01	H2001_886_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	887	0	1	04	01	H2001_887_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	888	0	1	04	01	H2001_888_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	889	0	1	04	01	H2001_889_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	890	0	1	04	01	H2001_890_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	891	0	1	04	01	H2001_891_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	892	0	1	04	01	H2001_892_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	893	0	1	04	01	H2001_893_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	894	0	1	04	01	H2001_894_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	895	0	1	04	01	H2001_895_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	896	0	1	04	01	H2001_896_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	897	0	1	04	01	H2001_897_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	898	0	1	04	01	H2001_898_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2001	899	0	1	04	01	H2001_899_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2032	001	0	1	04	01	H2032_001_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months. Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2																																																																																																																																																																					
H2032	002	0	1	04	01	H2032_002_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months. Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2																																																																																																																																																																					
H2032	003	0	1	04	01	H2032_003_0	11	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months. Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2																																																																																																																																																																					
H2032	801	0	1	04	01	H2032_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2032	802	0	1	04	01	H2032_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2032	803	0	1	04	01	H2032_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2032	804	0	1	04	01	H2032_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2034	001	0	1	01	01	H2034_001_0	5	2				2				2				2		1	2																																																																																																																																																																																																																																																																																						
H2035	001	0	1	01	01	H2035_001_0	5	2				1	20	20	20	2				2		1	1	2							2														2		2	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																												2								2					2		2	2	1	6	Restorative Crowns - 1 per tooth every 7 calendar years.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Prosthodontics - Rebases for full or partial dentures covered once every 2 calendar years. Replacement of all teeth & acrylic on cast metal frame covered once every 3 calendar years.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges) - 1 per tooth every 7 calendar years.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	One consultation is covered every calendar year.	2				1	0.00	0.00	0.00	1	2
H2041	001	0	1	01	01	H2041_001_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	002	0	1	01	01	H2041_002_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2041	003	0	1	01	01	H2041_003_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	004	0	1	01	01	H2041_004_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2041	005	0	1	01	01	H2041_005_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	006	0	1	01	01	H2041_006_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2041	007	0	1	01	01	H2041_007_0	4	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	008	0	1	01	01	H2041_008_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	009	0	1	01	01	H2041_009_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	010	0	1	01	01	H2041_010_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2041	011	0	1	01	01	H2041_011_0	4	2				1	30	30	30	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	012	0	1	01	01	H2041_012_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	013	0	1	01	01	H2041_013_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	014	0	1	01	01	H2041_014_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	015	0	1	01	01	H2041_015_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	016	0	1	01	01	H2041_016_0	4	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	017	0	1	01	01	H2041_017_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	018	0	1	01	01	H2041_018_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	021	0	1	01	01	H2041_021_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	022	0	1	01	01	H2041_022_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2041	023	0	1	01	01	H2041_023_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	024	0	1	01	01	H2041_024_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	025	0	1	01	01	H2041_025_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	026	0	1	01	01	H2041_026_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	027	0	1	01	01	H2041_027_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	028	0	1	01	01	H2041_028_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2041	029	0	1	01	01	H2041_029_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2056	003	0	1	01	01	H2056_003_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H2056	005	0	1	01	01	H2056_005_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H2056	018	0	1	01	01	H2056_018_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2056	801	0	1	01	01	H2056_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2056	802	0	1	01	01	H2056_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2056	804	0	1	01	01	H2056_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2064	001	0	1	20	08	H2064_001_0	1																																																																																																																																																																																																																																																																																																						
H2064	002	0	1	20	08	H2064_002_0	1																																																																																																																																																																																																																																																																																																						
H2085	001	0	1	20	08	H2085_001_0	1																																																																																																																																																																																																																																																																																																						
H2085	002	0	1	20	08	H2085_002_0	1																																																																																																																																																																																																																																																																																																						
H2108	022	0	1	01	01	H2108_022_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H2108	029	0	1	01	01	H2108_029_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		900.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2108	030	0	1	01	01	H2108_030_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2																																2	1				2				2				2	2																																																																																											2	1				2				2				2	2
H2108	041	0	1	01	01	H2108_041_0	6	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H2108	045	0	1	01	01	H2108_045_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		900.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2108	046	0	1	01	01	H2108_046_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		850.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2108	801	0	1	01	01	H2108_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2109	001	0	1	20	08	H2109_001_0	1																																																																																																																																																																																																																																																																																																						
H2109	002	0	1	20	08	H2109_002_0	1																																																																																																																																																																																																																																																																																																						
H2126	001	0	1	01	01	H2126_001_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2162	801	0	1	02	01	H2162_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2168	001	0	1	01	01	H2168_001_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	3	6	Periodic Oral evaluation 1 every 6 months.Limited oral evaluation 2 every 12 months.Comprehensive oral evaluation 1 per provider in a lifetime.Oral evaluation, problem focused 3 every 12 months, by report.	2				2				2	2	2	2	1	6	Intraoral, complete series or panoramic x-ray 1 every 36 months.  Intraoral, periapical  - 3 every 6 months; Intraoral, periapical 6 times every 12 months. Sialography - 2 every week	2				2				2	2	2	2	1	6	Cone beam CT capture and interpretation - 1 every 60 months.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	6	covered up to age of 20	2				2				2	2	2	2	1	6	Tobacco counseling, control prevention oral disease - 1 every 6 months.Unspecified preventive procedure, by report.	2				2				2	2	2								2					2		2	2	1	6	Amalgam / Resin based composite filling - 1 per tooth, per surface - every 24 months.Crown services - 1 per tooth - every 60 months.	2				2				1	2	2	2	1	6	Endodontic Services - 1 per tooth, per lifetime.	2				2				1	1	2	2	1	6	Gingivectomy or gingivopIasty - 1 every 12 months, per quad by report. Crown lengthening - 1 per tooth per ifetime.Periodontal scaling and root planing - 1 every 24 months per site/quad.Periodontal maintenance  once every 6 months.	2				2				1	1	2	2	1	6	Complete /Partial denture - 1 every 96 months, per arch.Denture Adjustment - 4 every 12 months, per arch (Not covered within 6 months of placement).	2				2				1	2	2	2	1	6	Maxillofacial Prosthetics covered 1 every 12 months.	2				2				1	2	2	2	1	6	Surgical placement of implant - 1 per tooth, in a lifetime.Abutment services - 1 per tooth, every 96 months.Debridement services - 1 per tooth, every 24 months.	2				2				1	2	2	2	1	6	1 every 60 months, per tooth	2				2				1	2	2	2	1	6	Extraction of erupted or impacted tooth 1 per tooth, in a lifetime. Alveoloplasty once per site/quad in a lifetime. Other Oral and Maxillofacial Surgery by report.	2				2				1	1																2	2	1	6	Palliative emergency treatment 2 every 12 months (Not reimbursable in addition to other therapeutic services performedat the same visit or in conjunction with initial or periodic oral examinations).  Deep sedation maximum of 60 minutes or 4 units.	2				2				1	2
H2168	002	0	1	01	01	H2168_002_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	3	6	Periodic Oral evaluation 1 every 6 months.Limited oral evaluation 2 every 12 months.Comprehensive oral evaluation 1 per provider in a lifetime.Oral evaluation, problem focused 3 every 12 months, by report.	2				2				2	2	2	2	1	6	Intraoral, complete series or panoramic x-ray 1 every 36 months.  Intraoral, periapical - 3 every 6 months; Intraoral, periapical 6 times every 12 months. Sialography - 2 every week	2				2				2	2	2	2	1	6	Cone beam CT capture and interpretation - 1 every 60 months.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	6	Covered up to age of 20	2				2				2	2	2	2	1	6	Tobacco counseling, control prevention oral disease - 1 every 6 months.Unspecified preventive procedure, by report.	2				2				2	2	2								2					2		2	2	1	6	Amalgam / Resin based composite filling - 1 per tooth, per surface - every 24 months.Crown services - 1 per tooth - every 60 months.	2				2				1	2	2	2	1	6	Endodontic Services - 1 per tooth, per lifetime.	2				2				1	1	2	2	1	6	Gingivectomy or gingivopIasty - 1 every 12 months, per quad by report. Crown lengthening - 1 per tooth per ifetime.Periodontal scaling and root planing - 1 every 24 months per site/quad.Periodontal maintenance  once every 6 months.	2				2				1	1	2	2	1	6	Complete /Partial denture - 1 every 96 months, per arch.Denture Adjustment - 4 every 12 months, per arch (Not covered within 6 months of placement).	2				2				1	2	2	2	1	6	Maxillofacial Prosthetics covered 1 every 12 months.	2				2				1	2	2	2	1	6	Surgical placement of implant - 1 per tooth, in a lifetime.Abutment services - 1 per tooth, every 96 months.Debridement services - 1 per tooth, every 24 months.	2				2				1	2	2	2	1	6	1 every 60 months, per tooth	2				2				1	2	2	2	1	6	Extraction of erupted or impacted tooth 1 per tooth, in a lifetime. Alveoloplasty once per site/quad in a lifetime.   Other Oral and Maxillofacial Surgery by report.	2				2				1	1																2	2	1	6	Palliative emergency treatment 2 every 12 months (Not reimbursable in addition to other therapeutic services performedat the same visit or in conjunction with initial or periodic oral examinations).  Deep sedation maximum of 60 minutes or 4 units.	2				2				1	2
H2168	004	0	1	01	01	H2168_004_0	5	2				1	20	20	20	2				2		2	2	1		900.00	4		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	6	Sialography, complete series or panoramic x-ray 1 every 3 calendar years. Bitewings - 4 every calendar year.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																1	1							2					2		2	2	1	6	Amalgam / Resin based composite filling - 1 per tooth, per surface - every 3 calendar years.Crown services - 1 per tooth - every 5 calendar years.	2				2				2	2	2	2	1	6	1 per tooth in a lifetime	2				2				2	2	2	2	1	6	Gingivectomy, Periodontal scaling and root planing 1 per site/quad every 2 calendar years Crown lengthening 1 per tooth in a life time	2				2				2	2	2	2	1	6	Complete /Partial denture - 1 every 5 calendar year, per arch.Denture Adjustment - 1 every calendar year, per arch	2				2				2	2																															2	2	1	6	1 per tooth every 5 calendar years	2				2				1	2	2	2	1	6	Alveoloplasty 1 per site / quad every 5 calendar years	2				2				2	2																2	2	1	6	Palliative emergency treatment 1 every Calendar year. Consultation 1 every 6 months	2				2				2	2
H2172	001	0	1	02	01	H2172_001_0	6	2				2				1	30.00	30.00	30.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	002	0	1	02	01	H2172_002_0	7	2				2				1	30.00	30.00	30.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	005	0	1	01	01	H2172_005_0	5	2				2				1	40.00	40.00	40.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	008	0	1	02	01	H2172_008_0	6	2				2				1	30.00	30.00	30.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	009	0	1	02	01	H2172_009_0	6	2				2				1	30.00	30.00	30.00	2		1	1	2							2				2	000000				1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	010	0	1	02	01	H2172_010_0	6	2				2				1	35.00	35.00	35.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	013	0	1	02	01	H2172_013_0	6	2				2				1	40.00	40.00	40.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		2000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	014	0	1	02	01	H2172_014_0	5	2				2				1	55.00	55.00	55.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1500.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	016	0	1	01	01	H2172_016_0	7	2				1	20	20	20	2				2		1	1	1		3000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	1							2					2		2	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.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	2				1	0.00	0.00	0.00	1	2	2	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.	2				1	0.00	0.00	0.00	1	2	2	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.	2				1	0.00	0.00	0.00	1	2																															2	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.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Extractions are limited to one per tooth.	1	20	20	20	2				1	2																2	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	2				1	0.00	0.00	0.00	1	2
H2172	017	0	1	01	01	H2172_017_0	6	2				1	20	20	20	2				2		1	1	1		3000.00	3		2		2				2	000000				1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	1							2					2		2	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.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	2				1	0.00	0.00	0.00	1	2	2	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.	2				1	0.00	0.00	0.00	1	2	2	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.	2				1	0.00	0.00	0.00	1	2																															2	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.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Extractions are limited to one per tooth.	1	20	20	20	2				1	2																2	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	2				1	0.00	0.00	0.00	1	2
H2172	018	0	1	01	01	H2172_018_0	6	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	1							2					2		2	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.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	2				1	0.00	0.00	0.00	1	2	2	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.	2				1	0.00	0.00	0.00	1	2	2	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.	2				1	0.00	0.00	0.00	1	2																															2	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.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Extractions are limited to one per tooth.	2				2				1	2																2	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	2				1	0.00	0.00	0.00	1	2
H2172	019	0	1	01	01	H2172_019_0	6	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	1							2					2		2	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.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	2				1	0.00	0.00	0.00	1	2	2	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.	2				1	0.00	0.00	0.00	1	2	2	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.	2				1	0.00	0.00	0.00	1	2																															2	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.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Extractions are limited to one per tooth.	2				2				1	2																2	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	2				1	0.00	0.00	0.00	1	2
H2172	020	0	1	02	01	H2172_020_0	6	2				2				1	40.00	40.00	40.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	021	0	1	02	01	H2172_021_0	6	2				2				1	40.00	40.00	40.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	022	0	1	02	01	H2172_022_0	6	2				2				1	45.00	45.00	45.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	023	0	1	02	01	H2172_023_0	6	2				2				1	35.00	35.00	35.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	024	0	1	02	01	H2172_024_0	6	2				2				1	45.00	45.00	45.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	025	0	1	01	01	H2172_025_0	6	2				2				1	45.00	45.00	45.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		500.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	026	0	1	01	01	H2172_026_0	6	2				2				1	55.00	55.00	55.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2																																																																																																																																																																					
H2172	027	0	1	02	01	H2172_027_0	6	2				2				1	45.00	45.00	45.00	2		1	1	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		500.00	3		2		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	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																															4	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	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	801	0	1	01	01	H2172_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2172	805	0	1	01	01	H2172_805_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2172	806	0	2	01	01	H2172_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2174	001	0	1	01	01	H2174_001_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2185	001	0	1	01	01	H2185_001_0	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2
H2185	003	0	1	02	01	H2185_003_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	4	3		2				2				2	2	2	2	4	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	4	3		2				2				2	2	2	2	2	4		2				2				2	2																1	2		2600.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2218	001	0	1	20	08	H2218_001_0	1																																																																																																																																																																																																																																																																																																						
H2218	002	0	1	20	08	H2218_002_0	1																																																																																																																																																																																																																																																																																																						
H2219	001	0	1	20	08	H2219_001_0	5																																																																																																																																																																																																																																																																																																						
H2219	002	0	1	20	08	H2219_002_0	5																																																																																																																																																																																																																																																																																																						
H2220	001	0	1	20	08	H2220_001_0	1																																																																																																																																																																																																																																																																																																						
H2220	002	0	1	20	08	H2220_002_0	1																																																																																																																																																																																																																																																																																																						
H2221	001	0	1	20	08	H2221_001_0	1																																																																																																																																																																																																																																																																																																						
H2221	002	0	1	20	08	H2221_002_0	1																																																																																																																																																																																																																																																																																																						
H2222	002	0	1	20	08	H2222_002_0	1																																																																																																																																																																																																																																																																																																						
H2222	003	0	1	20	08	H2222_003_0	1																																																																																																																																																																																																																																																																																																						
H2223	001	0	1	20	08	H2223_001_0	1																																																																																																																																																																																																																																																																																																						
H2223	002	0	1	20	08	H2223_002_0	1																																																																																																																																																																																																																																																																																																						
H2224	001	0	1	01	01	H2224_001_0	7	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	6	2 periodic oral evaluation per year.2 limited oral evaluation per year.1 Comprehensive oral or periodontal evaluation per calendar year.  1 per provider per lifetime.	2				2				2	2	2	2	1	6	1 intraoral comprehensive series of radiographic images per 3 years.12 of intraoral-periapical first and each additional radiographic image per 12 months.1 of panoramic radiographic image per 3 years.2 bitewings (1-4 images) per year.	2				2				1	2																2	2	2	3		2				2				1	2	2	2	1	6	1 of topical application of fluoride or fluoride varnish every 90 days	2				2				1	2	2	2	1	6	2 per application of caries arresting medicament per lifetime, per tooth	2				2				2	2	2								2					2		2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	Root canals-1 per lifetime per toothApicoectomy-1 per lifetime per tooth	2				2				1	2	2	2	1	6	Gingivectomy or gingivolplasty-1 per 3 years per quadrantPeriodontal scaling and root planing-1 per 3 years per quadrantScaling in presence of generalized moderat or severy gingival inflammation-2 per year.	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				2	2																															2	2	1	6	Medical Necessity	2				2				1	2	2	2	1	6	Alveoplasty-1 per 6 months per quadrant.Removal of exostosis-per site-1 per lifetime per arch.Removal of torus palatinus-1 per lifetime per arch.Removal of torus mandibularis-1 per lifetime per arch.Frenectomy-1 per lifteime per arch.Frenulectomy or frenuloplasty-1 per lifetime.	2				2				1	2																2	2	1	6	Palliative treatment- Other non-emergency medically necessarytreatment may be provided during thesame visit.house/ extended care facility observation - One of (D9410) per 1 Day(s)Per Business,Per facility.	2				2				1	2
H2224	003	0	1	01	01	H2224_003_0	7	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	6	2 periodic oral evaluation per year.2 limited oral evaluation per year.1 Comprehensive oral or periodontal evaluation per calendar year.  1 per provider per lifetime.	2				2				2	2	2	2	1	6	1 intraoral comprehensive series of radiographic images per 3 years.12 of intraoral-periapical first and each additional radiographic image per 12 months.1 of panoramic radiographic image per 3 years.2 bitewings (1-4 images) per year.	2				2				1	2																2	2	2	3		2				2				1	2	2	2	1	6	1 of topical application of fluoride or fluoride varnish every 90 days	2				2				1	2	2	2	1	6	2 per application of caries arresting medicament per lifetime, per tooth	2				2				2	2	2								2					2		2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	Root canals-1 per lifetime per toothApicoectomy-1 per lifetime per tooth	2				2				1	2	2	2	1	6	Gingivectomy or gingivolplasty-1 per 3 years per quadrantPeriodontal scaling and root planing-1 per 3 years per quadrantScaling in presence of generalized moderat or severy gingival inflammation-2 per year.	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				2	2																															2	2	1	6	Medical Necessity	2				2				1	2	2	2	1	6	Alveoplasty-1 per 6 months per quadrant.Removal of exostosis-per site-1 per lifetime per arch.Removal of torus palatinus-1 per lifetime per arch.Removal of torus mandibularis-1 per lifetime per arch.Frenectomy-1 per lifteime per arch.Frenulectomy or frenuloplasty-1 per lifetime.	2				2				1	2																2	2	1	6	Palliative treatment- Other non-emergency medically necessarytreatment may be provided during thesame visit.house/ extended care facility observation - One of (D9410) per 1 Day(s)Per Business,Per facility.	2				2				1	2
H2225	001	0	1	01	01	H2225_001_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Full mouth services of radiographs (FMX) 1 every 3 calendar years, Bitewing Radiographs 1 per calendar year, Panoramic Radiograph 1 every 3 years. Cone Beam scan 1 every 84 months.	2				2				2	2	2	2	1	6	As medically necessary. Additional services may require prior authorization.	2				2				1	2	2	2	4	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	1 mouthguard every 24 months	2				2				2	2	2								2					2		2	2	1	6	As medically necessary	2				2				1	2	2	2	1	6	As medically necessary	2				2				1	2	2	2	1	6	Perio maintenance covered 4 per calendar year. Additional services may be covered as medically necessary.	2				2				2	2	2	2	1	6	Complete and Partial Dentures 1 per 60 months, Immediate dentures 1 per lifetime.	2				2				2	2																2	2	1	6	The plan covers 4 implants per year. 1 per tooth per lifetime.	2				2				1	2	2	2	1	6	Per Lifetime	2				2				1	2	2	2	1	6	As medically necessary	2				2				2	2																2	2	1	6	Palliative treatment of dental pain per visit	2				2				2	2
H2226	001	0	1	01	01	H2226_001_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime  to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 3 years to unlimted.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per code per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 per 2 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities for each service in this category is unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 3 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicities will vary by service ranging from 1 per code per day to unlimited.	2				1	0.00	0.00	0.00	1	2
H2226	003	0	1	01	01	H2226_003_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime  to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 3 years to unlimted.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per code per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 per 2 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities for each service in this category is unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 3 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicities will vary by service ranging from 1 per code per day to unlimited.	2				1	0.00	0.00	0.00	1	2
H2230	002	0	1	04	01	H2230_002_0	9	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H2230	019	0	1	04	01	H2230_019_0	7	2				2				1	55.00	55.00	55.00	2		2	2	1	2	500.00	3		2		2				2					2					2		2	2	3	3		2				2				2	2	2	2	7	6	Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months. Bitewing X-rays once every 6 months. Single-tooth X-rays as needed.	2				2				2	2	2	2	1	6	Study models and casts used in planning treatment, once each 60 months	2				2				2	2	2	2	3	3		2				2				2	2																															1	1							2					2		2	2	1	6	Silver and white fillings: once per tooth in 12 months. Inlays: once per tooth in 60 months.	1	50	50	50	2				2	2	2	2	1	6	Root canals and retreatment of prior root canal on permanent teeth: once per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planning: once per quadrant per 24 months. Periodontal Surgery: once per quadrant per 36 months. Maintenance following active periodontal therapy: once within three months	1	50	50	50	2				2	2	2	2	1	6	See Notes Section for 16c4 for comprehensive list	1	50	50	50	2				2	2	2	2	1	6	See Notes Section for 16c5 for comprehensive list	1	50	50	50	2				2	2	2	2	1	6	See Notes Section for 16c6 for comprehensive list	1	50	50	50	2				2	2	2	2	1	6	See Notes Section for 16c7 for comprehensive list	1	50	50	50	2				2	2	2	2	1	6	See Notes Section for 16c8 for comprehensive list	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2230	020	0	1	04	01	H2230_020_0	7	2				2				1	45.00	45.00	45.00	2		2	2	1	2	575.00	3		2		2				2					2					2		2	2	3	3		2				2				2	2	2	2	7	6	Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months. Bitewing X-rays once every 6 months. Single-tooth X-rays as needed.	2				2				2	2	2	2	1	6	Study models and casts used in planning treatment, once each 60 months	2				2				2	2	2	2	3	3		2				2				2	2																															1	1							2					2		2	2	1	6	Silver and white fillings: once per tooth in 12 months. Inlays: once per tooth in 60 months.	1	50	50	50	2				2	2	2	2	1	6	Root canals and retreatment of prior root canal on permanent teeth: once per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planning: once per quadrant per 24 months. Periodontal Surgery: once per quadrant per 36 months. Maintenance following active periodontal therapy: once within three months	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c4 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c5 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c6 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c7 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c8 for comprehensive list.	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2230	801	0	1	04	01	H2230_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2230	809	0	1	04	01	H2230_809_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2230	813	0	1	04	01	H2230_813_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2235	001	0	1	01	01	H2235_001_0	9	2				2				3		15.00	150.00	2		2	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	See note below.	2				2				2	2	2	2	1	6	See note below.	2				2				2	2																2	2	2	6	A member is limited to two of any combination of the following: Scaling in the presence of generalized moderate or severe gingival inflammation, periodontal maintenance and prophylaxis.	2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	See note below.	3		0	50	2				1	1	2	2	2	3		2				2				1	1	2	2	2	6	See note below.	2				2				1	1	2	2	1	6	See note below.	3		0	50	2				1	1																															2	2	1	6	See note below.	1	50	50	50	2				1	1	2	2	1	6	Two extractions  every calendar year One extraction per tooth per lifetime	2				2				1	1																														
H2235	002	0	1	01	01	H2235_002_0	10	2				2				3		25.00	200.00	2		2	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	See note below.	2				2				2	2	2	2	1	6	See note below.	2				2				2	2																2	2	2	6	A member is limited to two of any combination of the following: Scaling in the presence of generalized moderate or severe gingival inflammation, periodontal maintenance and prophylaxis.	2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	See note below.	3		0	50	2				1	1	2	2	2	3		2				2				1	1	2	2	2	6	See note below.	2				2				1	1	2	2	1	6	See note below.	3		0	50	2				1	1																															2	2	1	6	See note below.	1	50	50	50	2				1	1	2	2	1	6	Two extractions  every calendar year One extraction per tooth per lifetime	2				2				1	1																														
H2237	007	0	1	01	01	H2237_007_0	4	2				1	20	20	20	2				2		1	1	1		4000.00	3		2		2				2					2					2		2	2	4	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam 1/yr, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	2	6	crown recement 1/5 yrs, crown 1/tooth/lifetime, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/3 yrs, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	2	6	bridge recement, bridges 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service unl/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H2247	001	0	1	02	01	H2247_001_0	4	2				1	20	20	20	2				2		1	2	1		750.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2247	003	0	1	02	01	H2247_003_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2247	004	0	1	01	01	H2247_004_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2247	006	1	1	01	01	H2247_006_1	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2247	006	2	1	01	01	H2247_006_2	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2256	001	1	1	01	01	H2256_001_1	8	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																						
H2256	001	2	1	01	01	H2256_001_2	7	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																						
H2256	001	6	1	01	01	H2256_001_6	8	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																						
H2256	015	1	1	01	01	H2256_015_1	7	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																						
H2256	015	2	1	01	01	H2256_015_2	7	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																						
H2256	015	6	1	01	01	H2256_015_6	8	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																						
H2256	016	1	1	01	01	H2256_016_1	4	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																						
H2256	016	2	1	01	01	H2256_016_2	4	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																						
H2256	018	1	1	01	01	H2256_018_1	9	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3				2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	018	7	1	01	01	H2256_018_7	9	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3				2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	018	8	1	01	01	H2256_018_8	9	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3				2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	019	1	1	01	01	H2256_019_1	4	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3				2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	019	7	1	01	01	H2256_019_7	4	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3				2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	026	1	1	01	01	H2256_026_1	9	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3				2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	026	2	1	01	01	H2256_026_2	9	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3				2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	026	3	1	01	01	H2256_026_3	9	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3				2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	033	0	1	01	01	H2256_033_0	7	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																						
H2256	034	0	1	01	01	H2256_034_0	9	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2		2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	036	0	1	01	01	H2256_036_0	9	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3		2		2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	039	0	1	01	01	H2256_039_0	4	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																						
H2256	040	0	1	01	01	H2256_040_0	4	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2		2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	041	0	1	01	01	H2256_041_0	4	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3		2		2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	042	0	1	01	01	H2256_042_0	4	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3		2		2				2					2					2		4	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	50	2				2	2	4	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	50	2				2	2																4	2	2	3		2				2				2	2																															1	1							2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	047	1	1	01	01	H2256_047_1	9	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3				2				2					2					2		2	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	50	2				2	2	2	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	50	2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	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	1	50	50	50	2				2	2	2	2	3	6	Covers 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	2	2	7	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 each for bone graft/guided tissue regeneration a lifetime.	1	50	50	50	2				2	2	2	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																															2	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	2	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	1	50	50	50	2				2	2																2	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.	1	50	50	50	2				2	2
H2256	047	2	1	01	01	H2256_047_2	9	2				2				1	40.00	40.00	40.00	2		1	1	1		750.00	3				2				2					2					2		2	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	50	2				2	2	2	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	50	2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	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	1	50	50	50	2				2	2	2	2	3	6	Covers 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	2	2	7	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 each for bone graft/guided tissue regeneration a lifetime.	1	50	50	50	2				2	2	2	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																															2	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	2	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	1	50	50	50	2				2	2																2	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.	1	50	50	50	2				2	2
H2256	047	3	1	01	01	H2256_047_3	9	2				2				1	40.00	40.00	40.00	2		1	1	1		500.00	3				2				2					2					2		2	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	50	2				2	2	2	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	50	2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	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	1	50	50	50	2				2	2	2	2	3	6	Covers 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	2	2	7	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 each for bone graft/guided tissue regeneration a lifetime.	1	50	50	50	2				2	2	2	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																															2	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	2	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	1	50	50	50	2				2	2																2	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.	1	50	50	50	2				2	2
H2256	801	0	1	01	01	H2256_801_0	3	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2256	802	0	1	01	01	H2256_802_0	3	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2256	803	0	1	01	01	H2256_803_0	3	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2256	808	0	1	01	01	H2256_808_0	3	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2261	005	0	1	01	01	H2261_005_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	One set of bitewings twice per calendar year.	2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H2261	024	0	1	02	01	H2261_024_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1		575.00	3		2		2				2					2					2		2	2	3	3		2				2				2	2	2	2	7	6	Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months. Bitewing X-rays once every 6 months. Single-tooth X-rays as needed.	2				2				2	2	2	2	1	6	Study models and casts used in planning treatment, once each 60 months	2				2				2	2	2	2	3	3		2				2				2	2																															1	1							2					2		2	2	1	6	Silver and white fillings: once per tooth in 12 months. Inlays: once per tooth in 60 months.	1	50	50	50	2				2	2	2	2	1	6	Root canals and retreatment of prior root canal on permanent teeth: once per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planning: once per quadrant per 24 months. Periodontal Surgery: once per quadrant per 36 months. Maintenance following active periodontal therapy: once within three months	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c4 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c5 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See notes for 16c6 for a comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c7 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c8 for comprehensive list.	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2261	025	0	1	02	01	H2261_025_0	8	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H2261	026	0	1	01	01	H2261_026_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	One set of bitewings twice per calendar year.	2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H2261	801	0	1	01	01	H2261_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2261	809	0	1	01	01	H2261_809_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2272	001	0	1	02	01	H2272_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2272	003	0	1	02	01	H2272_003_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2292	001	0	1	04	01	H2292_001_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2292	002	0	1	04	01	H2292_002_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2293	001	0	1	04	01	H2293_001_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	002	0	1	04	01	H2293_002_0	3	2				1	20	20	20	2				2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2293	004	0	1	04	01	H2293_004_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2293	009	0	1	04	01	H2293_009_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	010	0	1	04	01	H2293_010_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	014	0	1	04	01	H2293_014_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2293	016	0	1	04	01	H2293_016_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H2293	017	0	1	04	01	H2293_017_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2293	019	0	1	04	01	H2293_019_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H2293	021	0	1	04	01	H2293_021_0	3	2				1	20	20	20	2				2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2293	023	0	1	04	01	H2293_023_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	026	0	1	04	01	H2293_026_0	5	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H2293	029	0	1	04	01	H2293_029_0	3	2				2				1	48.00	48.00	48.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	031	0	1	04	01	H2293_031_0	3	2				2				1	59.00	59.00	59.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	033	0	1	04	01	H2293_033_0	3	2				2				1	49.00	49.00	49.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	039	0	1	04	01	H2293_039_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H2318	001	0	1	20	08	H2318_001_0	1																																																																																																																																																																																																																																																																																																						
H2318	002	0	1	20	08	H2318_002_0	1																																																																																																																																																																																																																																																																																																						
H2320	022	1	1	02	01	H2320_022_1	3	2				2				3		0.00	350.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	022	2	1	02	01	H2320_022_2	3	2				2				3		0.00	350.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	022	5	1	02	01	H2320_022_5	4	2				2				3		0.00	350.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	028	1	1	02	01	H2320_028_1	3	2				2				3		0.00	175.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	028	2	1	02	01	H2320_028_2	3	2				2				3		0.00	175.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	028	3	1	02	01	H2320_028_3	3	2				2				3		0.00	175.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	028	4	1	02	01	H2320_028_4	3	2				2				3		0.00	175.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	028	5	1	02	01	H2320_028_5	3	2				2				3		0.00	175.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	029	1	1	02	01	H2320_029_1	3	2				2				3		0.00	325.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	029	2	1	02	01	H2320_029_2	3	2				2				3		0.00	325.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	029	3	1	02	01	H2320_029_3	3	2				2				3		0.00	325.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	029	4	1	02	01	H2320_029_4	3	2				2				3		0.00	325.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	029	5	1	02	01	H2320_029_5	3	2				2				3		0.00	325.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	032	1	1	02	01	H2320_032_1	3	2				2				3		0.00	450.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	032	2	1	02	01	H2320_032_2	3	2				2				3		0.00	450.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	032	5	1	02	01	H2320_032_5	3	2				2				3		0.00	450.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	033	1	1	02	01	H2320_033_1	3	2				2				3		0.00	415.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	033	2	1	02	01	H2320_033_2	3	2				2				3		0.00	415.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	033	5	1	02	01	H2320_033_5	3	2				2				3		0.00	415.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	034	3	1	02	01	H2320_034_3	6	2				2				3		0.00	400.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	034	4	1	02	01	H2320_034_4	6	2				2				3		0.00	400.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	802	0	1	02	01	H2320_802_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2320	803	0	1	02	01	H2320_803_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2320	804	0	1	01	01	H2320_804_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2320	805	0	1	01	01	H2320_805_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2320	810	0	1	01	01	H2320_810_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2320	811	0	1	01	01	H2320_811_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2320	812	0	1	02	01	H2320_812_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2320	813	0	1	02	01	H2320_813_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2320	814	0	1	01	01	H2320_814_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2320	817	0	1	01	01	H2320_817_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2322	008	0	1	04	01	H2322_008_0	7	2				2				3		0.00	25.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		4	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																3													2	2
H2322	011	0	1	04	01	H2322_011_0	7	2				2				3		0.00	50.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		4	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																3													2	2
H2322	016	0	1	04	01	H2322_016_0	7	2				2				3		0.00	50.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		4	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																3													2	2
H2322	017	0	1	04	01	H2322_017_0	7	2				2				3		0.00	30.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		4	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																3													2	2
H2322	020	0	1	04	01	H2322_020_0	7	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Every 5 years	2				2				2	2	2	2	1	6	per lifetime	2				2				2	2	2	2	2	3		2				2				2	2																																														2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2322	801	0	1	04	01	H2322_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2322	803	0	1	04	01	H2322_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2354	015	0	1	01	01	H2354_015_0	7	2				2				3		0.00	45.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Every 5 years	3		50	75	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																3													2	2
H2354	018	0	1	01	01	H2354_018_0	8	2				2				3		0.00	50.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Every 5 years	3		50	75	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																3													2	2
H2354	019	0	1	01	01	H2354_019_0	6	2				2				3		0.00	35.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Every 5 years	3		50	75	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																3													2	2
H2354	021	0	1	02	01	H2354_021_0	8	2				2				3		0.00	30.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Every 5 years	3		50	75	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																3													2	2
H2354	025	0	1	01	01	H2354_025_0	7	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	every 5 years	2				2				2	2	2	2	1	6	Per lifetime	2				2				2	2	2	2	2	3		2				2				2	2																																														2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2354	028	0	1	01	01	H2354_028_0	7	2				2				3		0.00	40.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Every 5 years	3		50	75	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																3													2	2
H2354	029	0	1	01	01	H2354_029_0	7	2				2				3		0.00	25.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Every 5 years	3		50	75	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																3													2	2
H2354	030	0	1	01	01	H2354_030_0	7	2				2				3		0.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	every 5 years	2				2				2	2	2	2	1	6	Per lifetime	2				2				2	2	2	2	2	3		2				2				2	2																																														2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2354	801	0	1	01	01	H2354_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2354	802	0	1	01	01	H2354_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2354	806	0	1	02	01	H2354_806_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2354	807	0	1	02	01	H2354_807_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2368	001	0	1	20	08	H2368_001_0	1																																																																																																																																																																																																																																																																																																						
H2368	002	0	1	20	08	H2368_002_0	1																																																																																																																																																																																																																																																																																																						
H2384	001	0	1	20	08	H2384_001_0	1																																																																																																																																																																																																																																																																																																						
H2384	002	0	1	20	08	H2384_002_0	1																																																																																																																																																																																																																																																																																																						
H2385	001	0	1	04	01	H2385_001_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2385	002	0	1	04	01	H2385_002_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2385	003	0	1	04	01	H2385_003_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2385	004	0	1	04	01	H2385_004_0	4	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2386	001	0	1	20	08	H2386_001_0	1																																																																																																																																																																																																																																																																																																						
H2386	002	0	1	20	08	H2386_002_0	1																																																																																																																																																																																																																																																																																																						
H2392	001	0	1	01	01	H2392_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2392	003	0	1	01	01	H2392_003_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2397	001	0	1	20	08	H2397_001_0	1																																																																																																																																																																																																																																																																																																						
H2397	002	0	1	20	08	H2397_002_0	1																																																																																																																																																																																																																																																																																																						
H2400	001	0	1	01	01	H2400_001_0	3	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2		2					2		2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2
H2400	002	0	1	01	01	H2400_002_0	3	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2400.00	3		2		2					2		2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2
H2406	009	0	1	04	01	H2406_009_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	010	0	1	04	01	H2406_010_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	011	0	1	04	01	H2406_011_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	013	0	1	04	01	H2406_013_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	015	0	1	04	01	H2406_015_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	016	0	1	04	01	H2406_016_0	4	2				1	20	20	20	2				2		1	2	1	2	750.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	017	0	1	04	01	H2406_017_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	018	0	1	04	01	H2406_018_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	019	0	1	04	01	H2406_019_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	034	0	1	04	01	H2406_034_0	6	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	035	0	1	04	01	H2406_035_0	6	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	036	0	1	04	01	H2406_036_0	6	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	037	0	1	04	01	H2406_037_0	6	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	038	0	1	04	01	H2406_038_0	6	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	039	0	1	04	01	H2406_039_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	040	0	1	04	01	H2406_040_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	041	0	1	04	01	H2406_041_0	2	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	042	0	1	04	01	H2406_042_0	6	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	043	0	1	04	01	H2406_043_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	044	0	1	04	01	H2406_044_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	046	0	1	04	01	H2406_046_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	047	0	1	04	01	H2406_047_0	6	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	048	0	1	04	01	H2406_048_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	050	0	1	04	01	H2406_050_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2406	053	0	1	04	01	H2406_053_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2406	054	0	1	04	01	H2406_054_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	055	0	1	04	01	H2406_055_0	6	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	056	0	1	04	01	H2406_056_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	058	0	1	04	01	H2406_058_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	059	0	1	04	01	H2406_059_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	062	0	1	04	01	H2406_062_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	063	0	1	04	01	H2406_063_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	065	0	1	04	01	H2406_065_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	066	0	1	04	01	H2406_066_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	068	0	1	04	01	H2406_068_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	070	0	1	04	01	H2406_070_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	071	0	1	04	01	H2406_071_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	072	0	1	04	01	H2406_072_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	073	0	1	04	01	H2406_073_0	3	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	074	0	1	04	01	H2406_074_0	3	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	075	0	1	04	01	H2406_075_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	076	0	1	04	01	H2406_076_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2406	077	0	1	04	01	H2406_077_0	3	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	078	0	1	04	01	H2406_078_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	080	0	1	04	01	H2406_080_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	082	0	1	04	01	H2406_082_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	087	0	1	04	01	H2406_087_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	088	0	1	04	01	H2406_088_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	089	0	1	04	01	H2406_089_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	090	0	1	04	01	H2406_090_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	091	0	1	04	01	H2406_091_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2406	092	0	1	04	01	H2406_092_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	094	0	1	04	01	H2406_094_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	096	0	1	04	01	H2406_096_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2406	097	0	1	04	01	H2406_097_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2406	098	0	1	04	01	H2406_098_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	099	0	1	04	01	H2406_099_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2406	100	0	1	04	01	H2406_100_0	6	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	101	0	1	04	01	H2406_101_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	115	0	1	04	01	H2406_115_0	6	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	119	0	1	04	01	H2406_119_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	121	0	1	04	01	H2406_121_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	125	0	1	04	01	H2406_125_0	6	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	130	0	1	04	01	H2406_130_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	131	0	1	04	01	H2406_131_0	4	2				1	20	20	20	2				2		1	2	1	2	3500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	135	0	1	04	01	H2406_135_0	6	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	140	0	1	04	01	H2406_140_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	141	0	1	04	01	H2406_141_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	142	0	1	04	01	H2406_142_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2406	143	0	1	04	01	H2406_143_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	144	0	1	04	01	H2406_144_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2406	145	0	1	04	01	H2406_145_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2416	001	0	1	01	01	H2416_001_0	9	2				2				2				2		1	2																																																																																																																		2								2					2		2	2	1	3		2				2				1	2																															2	2	1	1		2				2				1	2																																																																																										
H2417	001	0	1	01	01	H2417_001_0	6	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H2419	001	0	1	01	01	H2419_001_0	7	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2422	002	0	1	01	01	H2422_002_0	7	2				1	20	20	20	2				2		2	2																																																																																																																		1	2		1500.00	3		2		2					2		2	1				2				2				2	2																																																																																																																																							
H2425	001	0	1	01	01	H2425_001_0	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2441	001	0	1	04	01	H2441_001_0	5	2				1	20	20	20	2				2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2445	001	0	1	02	01	H2445_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2445	002	0	1	02	01	H2445_002_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2445	003	0	1	02	01	H2445_003_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2445	004	0	1	02	01	H2445_004_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2450	007	0	1	18	06	H2450_007_0	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2450	016	0	1	18	06	H2450_016_0	7	2				2				3		0.00	25.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	030	0	1	18	06	H2450_030_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2450	032	0	1	18	06	H2450_032_0	3	2				2				3		0.00	25.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	033	0	1	18	06	H2450_033_0	3	2				2				3		0.00	15.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	034	0	1	18	06	H2450_034_0	3	2				2				3		0.00	15.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	036	0	1	18	06	H2450_036_0	3	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	038	0	1	18	06	H2450_038_0	3	2				2				3		0.00	30.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	039	0	1	18	06	H2450_039_0	7	2				2				3		0.00	30.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	043	0	1	18	06	H2450_043_0	3	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	044	0	1	18	06	H2450_044_0	3	2				2				3		15.00	60.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	046	0	1	18	06	H2450_046_0	3	2				2				3		10.00	25.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	049	0	1	18	06	H2450_049_0	7	2				2				3		15.00	60.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	050	0	1	18	06	H2450_050_0	3	2				2				3		20.00	60.00	2		2	2																																																																																																																																																																																																																																																																																						
H2450	051	0	1	18	06	H2450_051_0	3	2				2				3		10.00	45.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H2450	801	0	1	18	06	H2450_801_0	1																																																																																																																																																																																																																																																																																																						
H2458	002	0	1	01	01	H2458_002_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2461	005	0	1	18	06	H2461_005_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2461	006	0	1	18	06	H2461_006_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	6	2 routine ORAL EVAL per calendar year 1 COMPREHENSIVE PERIODONTAL EVAL per 3 years 1 DETAILED AND EXTENSIVE ORAL EVAL per 12 months,1 COMBINATION CONSULTATION AND A LIMITED oral eval per 12 months	2				2				1	2	2	2	1	6	4 BITEWING RADIOGRAPH  calendar year, or ONE FULL MOUTH RADIOGRAPH SERIES or INTRAORAL TOMOSYNTHESIS calendar year, or 4 PERIAPICAL IMAGES per 12 months, or one COMPREHENSIVE SERIES per 5 years	2				2				1	2																2	2	2	3		2				2				1	2																															1	1							2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H2461	007	0	1	18	06	H2461_007_0	2	2				2				2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	6	2 routine ORAL EVAL per calendar year 1 COMPREHENSIVE PERIODONTAL EVAL per 3 years 1 DETAILED AND EXTENSIVE ORAL EVAL per 12 months,1 COMBINATION CONSULTATION AND A LIMITED oral eval per 12 months	2				2				1	2	2	2	1	6	4 BITEWING RADIOGRAPH  calendar year, or ONE FULL MOUTH RADIOGRAPH SERIES or INTRAORAL TOMOSYNTHESIS calendar year, or 4 PERIAPICAL IMAGES per 12 months, or one COMPREHENSIVE SERIES per 5 years	2				2				1	2																2	2	2	3		2				2				1	2																															1	1							2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H2461	008	0	1	18	06	H2461_008_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2461	009	0	1	18	06	H2461_009_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	6	2 routine oral evaluations per calendar year, 1 Comprehensive Periodontal evaluation per 3 years, 1 detailed and extensive oral evaluation per 12 months, 1 combination consultation and a limited oral evaluation per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph per calendar year, or one full mouth radiograph series or intraoral tomosynthesis per calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2																															1	1							2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H2461	010	0	1	18	06	H2461_010_0	4	2				2				2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	6	2 routine ORAL EVAL per calendar year 1 COMPREHENSIVE PERIODONTAL EVAL per 3 years 1 DETAILED AND EXTENSIVE ORAL EVAL per 12 months,1 COMBINATION CONSULTATION AND A LIMITED oral eval per 12 months	2				2				1	2	2	2	1	6	4 BITEWING RADIOGRAPH  calendar year, or ONE FULL MOUTH RADIOGRAPH SERIES or INTRAORAL TOMOSYNTHESIS calendar year, or 4 PERIAPICAL IMAGES per 12 months, or one COMPREHENSIVE SERIES per 5 years	2				2				1	2																2	2	2	3		2				2				1	2																															1	1							2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H2462	026	0	1	18	06	H2462_026_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2462	027	0	1	18	06	H2462_027_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H2462	028	0	1	18	06	H2462_028_0	2	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H2462	801	0	1	18	06	H2462_801_0	1																																																																																																																																																																																																																																																																																																						
H2462	802	0	1	18	06	H2462_802_0	1																																																																																																																																																																																																																																																																																																						
H2463	001	0	1	01	01	H2463_001_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H2486	003	0	1	01	01	H2486_003_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	25.00	25.00	25.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				3		0.00	25.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H2486	005	0	1	01	01	H2486_005_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H2486	801	0	1	01	01	H2486_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2486	802	0	1	01	01	H2486_802_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2486	805	0	1	01	01	H2486_805_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2486	806	0	1	01	01	H2486_806_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2491	010	0	1	02	01	H2491_010_0	4	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2491	017	0	1	02	01	H2491_017_0	4	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2491	025	0	1	02	01	H2491_025_0	5	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2491	028	0	1	02	01	H2491_028_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2491	030	0	1	02	01	H2491_030_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2491	031	0	1	02	01	H2491_031_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H2491	034	0	1	02	01	H2491_034_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2491	035	0	1	02	01	H2491_035_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2491	036	0	1	02	01	H2491_036_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2491	037	0	1	02	01	H2491_037_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2491	038	0	1	02	01	H2491_038_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2509	001	0	1	02	01	H2509_001_0	4	2				1	20	20	20	2				2		1	2	1		4500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2509	002	0	1	02	01	H2509_002_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2509	003	0	1	02	01	H2509_003_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2526	001	0	1	04	01	H2526_001_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2526	002	0	1	04	01	H2526_002_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2526	003	0	1	04	01	H2526_003_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2541	001	0	1	20	08	H2541_001_0	1																																																																																																																																																																																																																																																																																																						
H2541	002	0	1	20	08	H2541_002_0	1																																																																																																																																																																																																																																																																																																						
H2561	001	0	1	01	01	H2561_001_0	9	2				2				1	35.00	35.00	35.00	2		2	1	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																													2	2	4	3		2				1	0.00	0.00	0.00	2	2																														
H2561	801	0	1	01	01	H2561_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2563	020	0	1	01	01	H2563_020_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	6	2 of periodic oral evaluation every 12 months1 comprehensive evaluation per provider/location per 36 months3 of  limited oral evaluation every 12 months	2				2				2	2	2	2	1	6	Please see notes section for description of x-ray coverage	2				2				2	2																2	2	2	6	2 visits/12 months	2				2				2	2	2	2	2	6	2 fluoride treatments per 12 months	2				2				2	2																1	2		4000.00	3		2		2					2		2	2	1	6	Please see notes section for description of Restorative Services	2				2				1	2	2	2	1	6	Please see notes section for description for description of Endodontics services	2				2				1	2	2	2	1	6	Please see notes section for description of Periodontics services	2				2				1	2	2	2	1	6	Please see notes section for description of Prosthodontics services	2				2				1	2																																														2	1				2				2				1	2																2	1				2				2				1	2
H2564	001	0	1	01	01	H2564_001_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		2700.00	3		2		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Pre and post-op radiographs required. Prior authorization required. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 months. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H2593	001	0	1	02	01	H2593_001_0	6	2				2				3		0.00	35.00	2		1	2	1		350.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H2593	003	0	1	01	01	H2593_003_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	005	0	1	02	01	H2593_005_0	5	2				2				3		0.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	006	0	1	02	01	H2593_006_0	5	2				2				3		0.00	35.00	2		1	2	1		1200.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	029	0	1	02	01	H2593_029_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H2593	031	0	1	02	01	H2593_031_0	4	2				1	20	20	20	2				2		1	2	1		2250.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	040	0	1	02	01	H2593_040_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	043	0	1	02	01	H2593_043_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		750.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2610	005	0	1	01	01	H2610_005_0	6	2				2				1	30.00	30.00	30.00	2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		250.00	3		1	1	2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	006	0	1	01	01	H2610_006_0	6	2				2				1	30.00	30.00	30.00	2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		1	1	2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	015	0	1	01	01	H2610_015_0	6	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		1	1	2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	016	0	1	01	01	H2610_016_0	5	2				2				1	30.00	30.00	30.00	2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2900.00	3		1	1	2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	021	0	1	01	01	H2610_021_0	5	2				2				1	35.00	35.00	35.00	2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2400.00	3		1	1	2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	027	0	1	01	01	H2610_027_0	6	2				2				1	25.00	25.00	25.00	2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2500.00	3		1	1	2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	030	0	1	01	01	H2610_030_0	6	2				2				1	35.00	35.00	35.00	2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		700.00	3		1	1	2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	803	0	1	01	01	H2610_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2610	804	0	1	01	01	H2610_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2610	805	0	1	01	01	H2610_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2610	806	0	1	01	01	H2610_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2610	807	0	1	02	01	H2610_807_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2610	808	0	1	02	01	H2610_808_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2610	809	0	1	02	01	H2610_809_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2610	810	0	1	02	01	H2610_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2624	005	0	1	01	01	H2624_005_0	8	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2																															1	2		1000.00	3		2		2					1	100.00	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2
H2628	001	0	1	01	01	H2628_001_0	9	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	3	6	Periodic oral evaluation: 1 every yrComprehensive oral evaluation: 1 every 5 yrs per providerComprehensive periodontal evaluation: 1 every yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	1 series of bitewing films: every 6 mo1 panoramic radiograph: every 5 yrsComprehensive series of radiographic images: 1 every 5 yrs per provider	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Cone beam CT capture: 1 every 5 yrs per providerDental and facial scan: by report	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2																2	2	2	6	Tobacco counseling, control prevention oral disease: 1 every 6 moOral health substance abuse counseling: 1 every 6 moCaries arrest treatment: 3 per tooth per yr	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Amalgam/Resin filings: unlimitedProtective/interim therapeutic restoration: 1 every 6 mo, 5 per tooth, lifetimeCore buildup: 1 per tooth every 6 moPin retention: 3 per tooth, lifetimeBand stabilization: 1 per tooth, lifetimeHydroxyapatite regeneration treatment: 2 per tooth every yr by report	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Gingivectomy: limited to correction of severe hyperplasia or hypertrophic gingivitisPeriodontal scaling and root planing: 1 per quad per 24 moPeriodontal maintenance: 1 per yr	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Complete/Partial dentures: 1 every 8 yrsDentures reline: 1 every 3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Unspecified maxillofacial prosthesis, by report medical necessity required	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Limited to implant removal, guided tissue regeneration, and replacement of restorative material. Accessing and retorquing loose implant screw, by report.Implant and Implant healing therapy are covered unlimited and requires authorization based on medical necessity.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Tooth removal: 1 tooth, lifetimeAlveoloplasty with extractions: 1 per quad, lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	First 15 min increment of general anesthesia & moderate analgesia: 1 per daySubsequent 15 min increment of general anesthesia & moderate analgesia: 4 per day	2				1	0.00	0.00	0.00	1	2
H2628	005	0	1	01	01	H2628_005_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1800.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2628	006	0	1	01	01	H2628_006_0	6	2				1	20	20	20	2				2		1	2	1		1800.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2628	007	0	1	01	01	H2628_007_0	9	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	3	6	Periodic oral evaluation: 1 every yrComprehensive oral evaluation: 1 every 5 yrs per providerComprehensive periodontal evaluation: 1 every yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	1 series of bitewing films: every 6 mo1 panoramic radiograph: every 5 yrsComprehensive series of radiographic images: 1 every 5 yrs per provider	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Cone beam CT capture: 1 every 5 yrs per providerDental and facial scan: by report	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2																2	2	2	6	Tobacco counseling, control prevention oral disease: 1 every 6 moOral health substance abuse counseling: 1 every 6 moCaries arrest treatment: 3 per tooth per yr	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Amalgam/Resin filings: unlimitedProtective/interim therapeutic restoration: 1 every 6 mo, 5 per tooth, lifetimeCore buildup: 1 per tooth every 6 moPin retention: 3 per tooth, lifetimeBand stabilization: 1 per tooth, lifetimeHydroxyapatite regeneration treatment: 2 per tooth every yr by report	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Gingivectomy: limited to correction of severe hyperplasia or hypertrophic gingivitisPeriodontal scaling and root planing: 1 per quad per 24 moPeriodontal maintenance: 1 per yr	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Complete/Partial dentures: 1 every 8 yrsDentures reline: 1 every 3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Unspecified maxillofacial prosthesis, by report medical necessity required	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Limited to implant removal, guided tissue regeneration, and replacement of restorative material. Accessing and retorquing loose implant screw, by report.Implant and Implant healing therapy are covered unlimited and requires authorization based on medical necessity.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Tooth removal: 1 tooth, lifetimeAlveoloplasty with extractions: 1 per quad, lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	First 15 min increment of general anesthesia & moderate analgesia: 1 per daySubsequent 15 min increment of general anesthesia & moderate analgesia: 4 per day	2				1	0.00	0.00	0.00	1	2
H2630	001	0	1	01	01	H2630_001_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2								2					2		2	2	2	3		2				3		0.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		25.00	1102.00	2	2																2	2	1	3		2				3		0.00	402.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		50.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H2630	002	0	1	01	01	H2630_002_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2								2					2		2	2	2	3		2				3		0.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		25.00	1102.00	2	2																2	2	1	3		2				3		0.00	402.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		50.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H2663	005	0	1	02	01	H2663_005_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	006	0	1	02	01	H2663_006_0	3	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	021	0	1	02	01	H2663_021_0	3	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	022	0	1	02	01	H2663_022_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	023	0	1	02	01	H2663_023_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	025	0	1	02	01	H2663_025_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	026	0	1	02	01	H2663_026_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	028	0	1	02	01	H2663_028_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	029	0	1	02	01	H2663_029_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	034	0	1	01	01	H2663_034_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	038	0	1	02	01	H2663_038_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	039	0	1	01	01	H2663_039_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	040	0	1	02	01	H2663_040_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	041	0	1	02	01	H2663_041_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	043	0	1	02	01	H2663_043_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	052	0	1	01	01	H2663_052_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	057	0	1	02	01	H2663_057_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	064	0	1	01	01	H2663_064_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	067	0	1	01	01	H2663_067_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	069	0	1	02	01	H2663_069_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	097	0	1	01	01	H2663_097_0	3	2				1	20	20	20	2				2		1	2	1		3250.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	098	0	1	01	01	H2663_098_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	100	0	1	01	01	H2663_100_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	102	0	1	01	01	H2663_102_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	103	0	1	02	01	H2663_103_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	104	0	1	01	01	H2663_104_0	3	2				2				1	49.00	49.00	49.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	105	0	1	02	01	H2663_105_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	107	0	1	01	01	H2663_107_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	108	0	1	01	01	H2663_108_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	109	0	1	01	01	H2663_109_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	110	0	1	01	01	H2663_110_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	111	0	1	01	01	H2663_111_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	112	0	1	01	01	H2663_112_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	113	0	1	01	01	H2663_113_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	114	0	1	01	01	H2663_114_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	116	0	1	01	01	H2663_116_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	117	0	1	01	01	H2663_117_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H2663	118	0	1	02	01	H2663_118_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2663	805	0	1	01	01	H2663_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2686	004	1	1	04	01	H2686_004_1	5	2				2				1	65.00	65.00	65.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2686	004	3	1	04	01	H2686_004_3	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2686	005	1	1	04	01	H2686_005_1	6	2				2				1	60.00	60.00	60.00	2		1	2	1	2	250.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2686	005	2	1	04	01	H2686_005_2	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2686	006	1	1	04	01	H2686_006_1	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2686	006	2	1	04	01	H2686_006_2	6	2				2				1	60.00	60.00	60.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2686	007	0	1	04	01	H2686_007_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2686	008	0	1	04	01	H2686_008_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2686	009	0	1	04	01	H2686_009_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2686	010	0	1	04	01	H2686_010_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2694	001	0	1	04	01	H2694_001_0	9	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2694	002	0	1	04	01	H2694_002_0	10	2				2				1	35.00	35.00	35.00	2		2	2	1	2	1750.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H2697	001	0	1	01	01	H2697_001_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	002	0	1	01	01	H2697_002_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	003	0	1	01	01	H2697_003_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2697	004	0	1	01	01	H2697_004_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	006	0	1	01	01	H2697_006_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2697	007	0	1	01	01	H2697_007_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	009	0	1	01	01	H2697_009_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2697	015	0	1	01	01	H2697_015_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	016	0	1	01	01	H2697_016_0	5	2				1	30	30	30	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2697	017	0	1	01	01	H2697_017_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2697	018	0	1	01	01	H2697_018_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2697	019	0	1	01	01	H2697_019_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	020	0	1	01	01	H2697_020_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2697	022	0	1	01	01	H2697_022_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	023	0	1	01	01	H2697_023_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	024	0	1	01	01	H2697_024_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	025	0	1	01	01	H2697_025_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	026	0	1	01	01	H2697_026_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	027	0	1	01	01	H2697_027_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2697	028	0	1	01	01	H2697_028_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2704	015	0	1	01	01	H2704_015_0	7	2				2				1	60.00	60.00	60.00	2		2	1	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	2		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																											2	2	1	6	Occlusal guard is provided once every 5 years.	2				1	0.00	0.00	0.00	2	2
H2704	016	0	1	01	01	H2704_016_0	7	2				2				1	60.00	60.00	60.00	2		2	1	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	2		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																											2	2	1	6	Occlusal guard is provided once every 5 years.	2				1	0.00	0.00	0.00	2	2
H2736	001	0	1	02	01	H2736_001_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2736	002	0	1	02	01	H2736_002_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2736	004	0	1	02	01	H2736_004_0	3	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2737	001	0	1	04	01	H2737_001_0	4	2				2				3		50.00	450.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2737	801	0	1	04	01	H2737_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2737	802	0	1	04	01	H2737_802_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2737	803	0	1	04	01	H2737_803_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2752	004	0	1	01	01	H2752_004_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2752	005	0	1	01	01	H2752_005_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		800.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2752	006	0	1	01	01	H2752_006_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2752	007	0	1	01	01	H2752_007_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2752	008	0	1	01	01	H2752_008_0	6	2				1	20	20	20	2				2		1	2	1		2550.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2752	009	0	1	01	01	H2752_009_0	6	2				2				1	5.00	5.00	5.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2775	106	0	1	04	01	H2775_106_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H2775	109	0	1	04	01	H2775_109_0	5	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H2775	111	0	1	04	01	H2775_111_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H2775	112	0	1	04	01	H2775_112_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 60 months or by report	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 3 months to 6 months	2				1	0.00	0.00	0.00	1	2	2	2	2	6	Every 12 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	Every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H2775	113	0	1	04	01	H2775_113_0	5	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H2775	115	0	1	04	01	H2775_115_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H2775	116	0	1	04	01	H2775_116_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2802	001	0	1	02	01	H2802_001_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	007	0	1	02	01	H2802_007_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	008	0	1	02	01	H2802_008_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	010	0	1	02	01	H2802_010_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	012	0	1	02	01	H2802_012_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	024	0	1	02	01	H2802_024_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	025	0	1	02	01	H2802_025_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	028	0	1	02	01	H2802_028_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	030	0	1	02	01	H2802_030_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	031	0	1	02	01	H2802_031_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	032	0	1	02	01	H2802_032_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	033	0	1	02	01	H2802_033_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	034	0	1	02	01	H2802_034_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	035	0	1	02	01	H2802_035_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	041	0	1	02	01	H2802_041_0	4	2				1	20	20	20	2				2		1	2	1		750.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	044	0	1	02	01	H2802_044_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	048	0	1	02	01	H2802_048_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	049	0	1	02	01	H2802_049_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	050	0	1	02	01	H2802_050_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	052	0	1	02	01	H2802_052_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	053	0	1	02	01	H2802_053_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2802	054	0	1	02	01	H2802_054_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	055	0	1	02	01	H2802_055_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	056	0	1	02	01	H2802_056_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	058	0	1	02	01	H2802_058_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	059	0	1	02	01	H2802_059_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	060	0	1	02	01	H2802_060_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	061	0	1	02	01	H2802_061_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	062	0	1	02	01	H2802_062_0	3	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	063	0	1	02	01	H2802_063_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	064	0	1	02	01	H2802_064_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2802	067	0	1	02	01	H2802_067_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	068	0	1	02	01	H2802_068_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	070	0	1	02	01	H2802_070_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	071	0	1	02	01	H2802_071_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	072	0	1	02	01	H2802_072_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	073	0	1	02	01	H2802_073_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	074	0	1	02	01	H2802_074_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	075	0	1	02	01	H2802_075_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	076	0	1	02	01	H2802_076_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	077	0	1	02	01	H2802_077_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	078	0	1	02	01	H2802_078_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	079	0	1	02	01	H2802_079_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	082	0	1	02	01	H2802_082_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	084	0	1	02	01	H2802_084_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	086	0	1	02	01	H2802_086_0	3	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	087	0	1	02	01	H2802_087_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	088	0	1	02	01	H2802_088_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H2802	090	0	1	02	01	H2802_090_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2802	091	0	1	02	01	H2802_091_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H2802	094	0	1	02	01	H2802_094_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H2802	801	0	1	01	01	H2802_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	802	0	1	01	01	H2802_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	803	0	1	01	01	H2802_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	804	0	1	01	01	H2802_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	805	0	1	01	01	H2802_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	806	0	1	01	01	H2802_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	807	0	1	01	01	H2802_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	808	0	1	01	01	H2802_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	809	0	1	01	01	H2802_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	816	0	1	01	01	H2802_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	817	0	1	01	01	H2802_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	818	0	1	01	01	H2802_818_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	819	0	1	01	01	H2802_819_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	820	0	1	01	01	H2802_820_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	821	0	1	01	01	H2802_821_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	822	0	1	01	01	H2802_822_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	823	0	1	01	01	H2802_823_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2802	824	0	1	01	01	H2802_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H2815	001	0	1	20	08	H2815_001_0	1																																																																																																																																																																																																																																																																																																						
H2815	002	0	1	20	08	H2815_002_0	1																																																																																																																																																																																																																																																																																																						
H2816	804	0	1	09	04	H2816_804_0	3	2				3		20	20	2				2																																																																																																																																																																																																																																																																																									
H2819	001	0	1	01	01	H2819_001_0	7	2				1	20	20	20	2				2		2	1	2							2				2					2					2		2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2																																														2								2					2		2	2	2	3		2				2				1	1																2	2	1	1		2				2				1	1	2	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				2				1	1																															2	2	1	6	Benefits in this category are covered once per tooth every 5 calendar years.	2				2				1	1	2	2	1	6	Benefits in this category are covered once in a lifetime per site.	2				2				1	1																2	1				2				2				2	2
H2835	001	0	1	20	08	H2835_001_0	1																																																																																																																																																																																																																																																																																																						
H2835	002	0	1	20	08	H2835_002_0	1																																																																																																																																																																																																																																																																																																						
H2836	006	0	1	04	01	H2836_006_0	5	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2845	001	0	1	04	01	H2845_001_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2845	002	0	1	04	01	H2845_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2845	003	0	1	04	01	H2845_003_0	5	2				1	30	30	30	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2845	005	0	1	04	01	H2845_005_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2845	006	0	1	04	01	H2845_006_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2845	008	0	1	04	01	H2845_008_0	5	2				1	30	30	30	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2845	009	0	1	04	01	H2845_009_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2845	010	0	1	04	01	H2845_010_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2845	011	0	1	04	01	H2845_011_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2845	012	0	1	04	01	H2845_012_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2845	013	0	1	04	01	H2845_013_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2845	014	0	1	04	01	H2845_014_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2851	001	0	1	01	01	H2851_001_0	9	2				2				1	30.00	30.00	30.00	2		2	2	1		1250.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2853	801	0	1	01	01	H2853_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H2875	001	0	1	02	01	H2875_001_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H2875	002	0	1	02	01	H2875_002_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H2875	003	0	1	01	01	H2875_003_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H2875	004	0	1	01	01	H2875_004_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H2875	005	0	1	01	01	H2875_005_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H2875	006	0	1	02	01	H2875_006_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H2882	003	0	1	20	08	H2882_003_0	1																																																																																																																																																																																																																																																																																																						
H2882	004	0	1	20	08	H2882_004_0	1																																																																																																																																																																																																																																																																																																						
H2915	002	0	1	02	01	H2915_002_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth Every 7 plan years. Other restorative Every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per plan year, and once per same tooth Every 7 plan years; other implant services Every year to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth Every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2915	003	0	1	02	01	H2915_003_0	4	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2915	018	0	1	02	01	H2915_018_0	5	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H2918	001	0	1	20	08	H2918_001_0	1																																																																																																																																																																																																																																																																																																						
H2918	002	0	1	20	08	H2918_002_0	1																																																																																																																																																																																																																																																																																																						
H2923	001	0	1	01	01	H2923_001_0	7	2				2				1	40.00	40.00	40.00	2		1	2	1		1750.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	005	0	1	01	01	H2923_005_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	009	0	1	01	01	H2923_009_0	5	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2923	011	0	1	01	01	H2923_011_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	012	0	1	01	01	H2923_012_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2923	013	0	1	01	01	H2923_013_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2923	014	0	1	01	01	H2923_014_0	4	2				1	30	30	30	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2923	018	0	1	01	01	H2923_018_0	3	2				2				1	55.00	55.00	55.00	2		1	2	1		1250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	019	0	1	01	01	H2923_019_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	020	0	1	01	01	H2923_020_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	022	0	1	01	01	H2923_022_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	024	0	1	01	01	H2923_024_0	3	2				2				1	55.00	55.00	55.00	2		1	2	1		1250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	025	0	1	01	01	H2923_025_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	026	1	1	01	01	H2923_026_1	7	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	026	2	1	01	01	H2923_026_2	7	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	027	1	1	01	01	H2923_027_1	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	027	2	1	01	01	H2923_027_2	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	028	1	1	01	01	H2923_028_1	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2923	028	2	1	01	01	H2923_028_2	7	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2923	028	3	1	01	01	H2923_028_3	7	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3				2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H2923	029	0	1	01	01	H2923_029_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		1250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2923	030	0	1	01	01	H2923_030_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		1250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H2926	001	0	1	01	01	H2926_001_0	9	2				2				2				2		1	2																																																																																																																		2								2					2		2	2	1	3		2				2				1	2																																																																																																																																							
H2936	001	0	1	20	08	H2936_001_0	1																																																																																																																																																																																																																																																																																																						
H2936	002	0	1	20	08	H2936_002_0	1																																																																																																																																																																																																																																																																																																						
H2937	001	0	1	20	08	H2937_001_0	1																																																																																																																																																																																																																																																																																																						
H2937	002	0	1	20	08	H2937_002_0	1																																																																																																																																																																																																																																																																																																						
H2941	001	0	1	20	08	H2941_001_0	1																																																																																																																																																																																																																																																																																																						
H2941	002	0	1	20	08	H2941_002_0	1																																																																																																																																																																																																																																																																																																						
H2942	001	0	1	01	01	H2942_001_0	10	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Intra oral bitewing X-ray when oral conditions indicate need: 2x per calendar year. X-ray of entire mouth, 1x per 5 years. Single tooth X-rays covered as needed.	2				2				2	2	2	2	1	6	Emergency oral evaluation problem-focused exams: covered once every calendar year. Diagnostic casts (study model): covered once every 36 months.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	1		2				2				2	2	1	1							2					2		2	2	1	6	See notes below.	3		0	40	2				2	2	2	2	1	6	Root Canal: 1x per tooth per lifetime. Retreatment Root Canal Therapy: 1x per tooth per lifetime at least 24 months after initial root canal. Apicoectomy: as needed. Retrograde filling: 1x per tooth	2				2				2	2	2	2	1	6	maintenance: 2x every 12 months following active periodontal therapy; not to be combined with regular cleanings. Scaling and Root Planning: 1x every 24 months per quadrant. Full mouth debridement: 1x	2				2				2	2	2	2	1	6	Dentures (complete or partial): one covered per arch within 7 years	1	40	40	40	2				2	2																															2	2	1	6	Fixed Bridges: covered once every 84 months.	1	40	40	40	2				2	2	2	2	1	6	Surgical Extractions: covered once per tooth	2				2				2	2																2	2	1	6	General Anesthesia, analgesia and IV sedation: allowed with covered oral surgery	1	40	40	40	2				2	2
H2942	002	0	1	01	01	H2942_002_0	10	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Intra oral bitewing X-ray when oral conditions indicate need: 2x per calendar year. X-ray of entire mouth, 1x per 5 years. Single tooth X-rays covered as needed.	2				2				2	2	2	2	1	6	Emergency oral evaluation problem-focused exams: covered once every calendar year. Diagnostic casts (study model): covered once every 36 months.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	1		2				2				2	2	1	1							2					2		2	2	1	6	See notes below.	3		0	40	2				2	2	2	2	1	6	Root Canal: 1x per tooth per lifetime. Retreatment Root Canal Therapy: 1x per tooth per lifetime at least 24 months after initial root canal. Apicoectomy: as needed. Retrograde filling: 1x per tooth	2				2				2	2	2	2	1	6	maintenance: 2x every 12 months following active periodontal therapy; not to be combined with regular cleanings. Scaling and Root Planning: 1x every 24 months per quadrant. Full mouth debridement: 1x	2				2				2	2	2	2	1	6	Dentures (complete or partial): one covered per arch within 7 years	1	40	40	40	2				2	2																															2	2	1	6	Fixed Bridges: covered once every 84 months.	1	40	40	40	2				2	2	2	2	1	6	Surgical Extractions: covered once per tooth	2				2				2	2																2	2	1	6	General Anesthesia, analgesia and IV sedation: allowed with covered oral surgery	1	40	40	40	2				2	2
H2942	003	0	1	01	01	H2942_003_0	10	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Intra oral bitewing X-ray when oral conditions indicate need: 2x per calendar year. X-ray of entire mouth, 1x per 5 years. Single tooth X-rays covered as needed.	2				2				2	2	2	2	1	6	Emergency oral evaluation problem-focused exams: covered once every calendar year. Diagnostic casts (study model): covered once every 36 months.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	1		2				2				2	2	1	1							2					2		2	2	1	6	See notes below.	3		0	40	2				2	2	2	2	1	6	Root Canal: 1x per tooth per lifetime. Retreatment Root Canal Therapy: 1x per tooth per lifetime at least 24 months after initial root canal. Apicoectomy: as needed. Retrograde filling: 1x per tooth	2				2				2	2	2	2	1	6	maintenance: 2x every 12 months following active periodontal therapy; not to be combined with regular cleanings. Scaling and Root Planning: 1x every 24 months per quadrant. Full mouth debridement: 1x	2				2				2	2	2	2	1	6	Dentures (complete or partial): one covered per arch within 7 years	1	40	40	40	2				2	2																															2	2	1	6	Fixed Bridges: covered once every 84 months.	1	40	40	40	2				2	2	2	2	1	6	Surgical Extractions: covered once per tooth	2				2				2	2																2	2	1	6	General Anesthesia, analgesia and IV sedation: allowed with covered oral surgery	1	40	40	40	2				2	2
H2960	009	0	1	01	01	H2960_009_0	4	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	INTRAORAL COMPLETE SERIES OR PANORAMIC RADIOGRAPHIC IMAGES: COVERED ONCE EVERY 3 CALENDAR YEARS	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	1	6	Amalgams or resin covered once per surface per tooth every 3 calendar years. Inlay, onlay or crowns covered once per tooth every 5 calendar years. 	1	0	0	0	2				2	2	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	1	0	0	0	2				2	2	2	2	1	6	PERIODONTIC SERVICES- COVERED ONCE PER SITE PER QUADRANT EVERY 24 MONTHS. PERIODONTAL MAINTENANCE COVERED TWICE EVERY CALEANDAR YEAR.FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARS	1	0	0	0	2				2	2	2	2	1	6	PROSTHODONTIC SERVICES- IMMEDIATE DENTURES COVERED ONCE PER ARCH PER 5 YEARS.REMOVABLE COMPLETE OR PARTIAL DENTURES IN RESIN AND METAL BASE, COVERED EVERY 5 YEARS.	1	0	0	0	2				2	2																																														2	2	1	6	ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1	0	0	0	2				2	2																														
H2960	024	0	1	01	01	H2960_024_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	1	6	Amalgams or resin covered once per surface per tooth every 3 calendar years. Inlay, onlay or crowns covered once per tooth every 5 calendar years.	1	0	0	0	2				2	2	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	1	0	0	0	2				2	2	2	2	1	6	FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARSOSSEOUS SURGERY COVERED ONCE PER SITE PER QUADRANT EVERY 2 CALENDAR YEARS	1	0	0	0	2				2	2	2	2	1	6	PROSTHODONTIC SERVICES- IMMEDIATE DENTURES COVERED ONCE PER ARCH PER 5 YEARS.REMOVABLE COMPLETE OR PARTIAL DENTURES IN RESIN AND METAL BASE, COVERED EVERY 5 YEARS.	1	0	0	0	2				2	2																																														2	2	1	6	ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1	0	0	0	2				2	2																														
H2960	028	0	1	01	01	H2960_028_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	1	6	RESTORATIVE SERVICES- AMALGAMS OR RESIN COVERED ONCE PER SURFACE PER TOOTH EVERY 3 CALENDAR YEARS.INLAY, ONLAY, OR CROWNS: COVERED ONCE PER TOOTH PER 5 CALENDAR YEARS	1	0	0	0	2				2	2	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	1	0	0	0	2				2	2	2	2	1	6	PERIODONTIC SERVICES- COVERED ONCE PER SITE PER QUADRANT EVERY 24 MONTHS. PERIODONTAL MAINTENANCE COVERED TWICE EVERY CALEANDAR YEAR.FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARS	1	0	0	0	2				2	2	2	2	1	6	PROSTHODONTIC SERVICES- IMMEDIATE DENTURES COVERED ONCE PER ARCH PER 5 YEARS.REMOVABLE COMPLETE OR PARTIAL DENTURES IN RESIN AND METAL BASE, COVERED EVERY 5 YEARS.	1	0	0	0	2				2	2																																														2	2	1	6	ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1	0	0	0	2				2	2																														
H2960	029	0	1	01	01	H2960_029_0	7	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	6	ITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR.	2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H2960	803	0	1	01	01	H2960_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H2962	001	0	1	01	01	H2962_001_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2																2	1				2				2				1	2																																																													2	1				2				2				1	2																2	1				2				2				1	2
H2962	021	0	1	01	01	H2962_021_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																														2	1				2				2				1	2																2	1				2				2				1	2
H2962	023	0	1	01	01	H2962_023_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																														2	1				2				2				1	2																2	1				2				2				1	2
H2962	026	0	1	01	01	H2962_026_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																																													2	1				2				2				1	2																2	1				2				2				1	2
H2962	028	0	1	01	01	H2962_028_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2																2	1				2				2				1	2																																																													2	1				2				2				1	2																2	1				2				2				1	2
H2962	029	0	1	01	01	H2962_029_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																														2	1				2				2				1	2																2	1				2				2				1	2
H2962	033	0	1	01	01	H2962_033_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																																													2	1				2				2				1	2																2	1				2				2				1	2
H2962	035	0	1	01	01	H2962_035_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																														2	1				2				2				1	2																2	1				2				2				1	2
H2962	036	0	1	01	01	H2962_036_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																														2	1				2				2				1	2																2	1				2				2				1	2
H2962	045	0	1	01	01	H2962_045_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2																2	1				2				2				1	2																																																													2	1				2				2				1	2																2	1				2				2				1	2
H2962	046	0	1	01	01	H2962_046_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2																2	1				2				2				1	2																																																													2	1				2				2				1	2																2	1				2				2				1	2
H2962	047	0	1	01	01	H2962_047_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2																2	1				2				2				1	2																																																													2	1				2				2				1	2																2	1				2				2				1	2
H2962	050	0	1	01	01	H2962_050_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																																													2	1				2				2				1	2																2	1				2				2				1	2
H2962	051	0	1	01	01	H2962_051_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																																													2	1				2				2				1	2																2	1				2				2				1	2
H2962	052	0	1	01	01	H2962_052_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																																													2	1				2				2				1	2																2	1				2				2				1	2
H2962	053	0	1	01	01	H2962_053_0	6	2				2				2				2		2	2	2							2				2					2					2		2	2	2	6	 1 oral evaluation every 6 months} 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:} 2 dental x-ray every year}}Xrays may include:}Intraoral, periapical first radiographic image}Intraoral, periapical each additional radiographic image}Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																														2	1				2				2				1	2																2	1				2				2				1	2
H2992	001	0	1	20	08	H2992_001_0	1																																																																																																																																																																																																																																																																																																						
H2992	002	0	1	20	08	H2992_002_0	1																																																																																																																																																																																																																																																																																																						
H2992	003	0	1	20	08	H2992_003_0	1																																																																																																																																																																																																																																																																																																						
H2992	004	0	1	20	08	H2992_004_0	1																																																																																																																																																																																																																																																																																																						
H3012	001	0	1	01	01	H3012_001_0	4	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	 Single bitewing X-rays allowed 1 time every 12 months from last date of service.  Full mouth series or panoramic X-rays allowed 1 time every 5 years from last date of service.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2																2	1				2				2				2	2																																																																																																																																																																					
H3012	002	0	1	01	01	H3012_002_0	4	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	 Single bitewing X-rays allowed 1 time every 12 months from last date of service.  Full mouth series or panoramic X-rays allowed 1 time every 5 years from last date of service.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2																2	1				2				2				2	2																																																																																																																																																																					
H3012	003	0	1	01	01	H3012_003_0	4	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	 Single bitewing X-rays allowed 1 time every 12 months from last date of service.  Full mouth series or panoramic X-rays allowed 1 time every 5 years from last date of service.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2																2	1				2				2				2	2																																																																																																																																																																					
H3038	004	1	1	01	01	H3038_004_1	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3038	004	2	1	01	01	H3038_004_2	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3038	004	3	1	01	01	H3038_004_3	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3038	004	4	1	01	01	H3038_004_4	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3041	001	0	1	01	01	H3041_001_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H3048	001	0	1	01	01	H3048_001_0	5	2				1	20	20	20	2				2		1	2	1		1940.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	2	6	Complete set of radiographic images - 1 every 36 monthsBitewing (1 to 4 images) - 2 every 12 monthsPanoramic radiographic image - 1 every 36 months	2								2	2																2	2	1	4		2								2	2	2	2	1	4		2								2	2																1	1							2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic therapy (anterior, premolar, molar) and retreatment of previous root canal therapy (anterior, premolar, molar) - 1 per tooth per lifetime	2				1	0.00	0.00	0.00	2	2	2	2	3	6	Scaling and root planing four or more teeth per quadrant - 1 per quadrant per 24 monthsFull mouth debridgement - 1 per 12 monthsPeriodontal maintenance - 1 every 6 months	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Complete or partial denture - 1 per arch per 60 monthsAdjust complete or partial denture, adjust complete or partial denture, or chairside reline complete or partial denture - 1 per arch per 12 months	2				1	0.00	0.00	0.00	2	2																2	2	2	6	Surgical replacements of implant body - 1 per tooth per lifetimeProcelain/ceramic crown or metal crown - 1 per tooth per 60 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	1 per arch per 60 months	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2
H3048	002	0	1	01	01	H3048_002_0	6	2				1	20	20	20	2				2		1	2	1		900.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	2	6	Complete set of radiographic images - 1 every 36 monthsBitewing (1 to 4 images) - 2 every 12 monthsPanoramic radiographic image - 1 every 36 months	2								2	2																2	2	1	4		2								2	2	2	2	1	4		2								2	2																1	1							2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic therapy (anterior, premolar, molar) and retreatment of previous root canal therapy (anterior, premolar, molar) - 1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	3	6	Scaling and root planing four or more teeth per quadrant - 1 per quadrant per 24 monthsFull mouth debridgement - 1 per 12 monthsPeriodontal maintenance - 1 every 6 months	2				1	0.00	0.00	0.00	1	2	2	2	2	6	Complete or partial denture - 1 per arch per 60 monthsAdjust complete or partial denture, adjust complete or partial denture, or chairside reline complete or partial denture - 1 per arch per 12 months	2				1	0.00	0.00	0.00	1	2																2	2	2	6	Surgical replacements of implant body - 1 per tooth per lifetimeProcelain/ceramic crown or metal crown - 1 per tooth per 60 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	1 per arch per 60 months	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2
H3048	003	0	1	01	01	H3048_003_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1450.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	2	6	Complete set of radiographic images - 1 every 36 monthsBitewing (1 to 4 images) - 2 every 12 monthsPanoramic radiographic image - 1 every 36 months	2								2	2																2	2	1	4		2								2	2	2	2	1	4		2								2	2																1	1							2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic therapy (anterior, premolar, molar) and retreatment of previous root canal therapy (anterior, premolar, molar) - 1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	3	6	Scaling and root planing four or more teeth per quadrant - 1 per quadrant per 24 monthsFull mouth debridgement - 1 per 12 monthsPeriodontal maintenance - 1 every 6 months	2				1	0.00	0.00	0.00	1	2	2	2	2	6	Complete or partial denture - 1 per arch per 60 monthsAdjust complete or partial denture, adjust complete or partial denture, or chairside reline complete or partial denture - 1 per arch per 12 months	2				1	0.00	0.00	0.00	1	2																2	2	2	6	Surgical replacements of implant body - 1 per tooth per lifetimeProcelain/ceramic crown or metal crown - 1 per tooth per 60 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	1 per arch per 60 months	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2
H3048	004	0	1	01	01	H3048_004_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					1	110110	0.00	0.00	0.00	2		2	2	4	3		2								2	2	2	2	1	6	Complete series of radiographic images - 1 every 36 monthsBitewing images (1 to 4 images) - 2 every 12 monthsPanoramic image - 1 every 36 months	2								2	2																2	2	1	4		2								2	2	2	2	1	4		2								2	2																2								2					2		2	2	2	6	Amalgam and resin based composites - 2 per tooth per surface every 12 months	2				1	0.00	0.00	0.00	1	2																2	2	7	3		2				1	0.00	0.00	0.00	1	2																																																													2	2	2	6	Up to 2 extractions per year	2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	2	2
H3060	001	0	1	20	08	H3060_001_0	1																																																																																																																																																																																																																																																																																																						
H3060	002	0	1	20	08	H3060_002_0	1																																																																																																																																																																																																																																																																																																						
H3080	001	0	1	01	01	H3080_001_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H3080	002	0	1	01	01	H3080_002_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H3080	003	0	1	01	01	H3080_003_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H3080	004	0	1	01	01	H3080_004_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H3080	006	0	1	01	01	H3080_006_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H3080	007	0	1	01	01	H3080_007_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H3084	001	0	1	20	08	H3084_001_0	1																																																																																																																																																																																																																																																																																																						
H3084	002	0	1	20	08	H3084_002_0	1																																																																																																																																																																																																																																																																																																						
H3093	002	0	1	01	01	H3093_002_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	1 periodic oral evaluation (established patient) or comprehensive oral evaluation every 6 months per patient; Comprehensive oral evaluation limited to 1 per lifetime per patient, per provider; 1 problem focused exam per day per patient, per provider.	2				2				2	2	2	2	1	6	Intraoral complete series or panoramic radiographic imaging: 1 every 36 months; Bitewing radiographs: up to 8 per 12 months; Periapical radiographic images: 1 per day per patient, per provider.	2				2				2	2																2	2	2	6	Adult prophylaxis: 1 every 6 months per patient.	2				2				2	2																															1	2		3000.00	3		2		2					2		2	2	1	6	Amalgam and composite restorations: 1 per tooth per 12 months per surface per patient; Onlays and crowns (porcelain/ceramic, metal, or fused): 1 per tooth every 60 months; Prefabricated crowns (permanent): 1 per tooth every 60 months; Core buildup and post procedures: 1 per tooth per 60 months.	2				2				1	2	2	2	1	6	Root canal therapy (excluding final restoration): 1 per tooth per lifetime per patient.	2				2				1	2	2	2	1	6	Scaling and root planing: 1 per quadrant every 24 months; Periodontal maintenance: 1 per year per patient; Gingivectomy and surgical periodontal procedures: 1 per quadrant every 24 months.	2				2				1	2	2	2	1	6	Complete, immediate, or partial dentures every 60 months per patient; Relines: 1 every 24 months.	2				2				1	2																																														2	2	1	6	Simple extractions covered per clinical criteria; Impacted tooth removal subject to medical necessity; Incision and drainage: 1 per day; Alveoloplasty in conjunction with extractions: 1 per quadrant per lifetime.	2				2				1	2																2	2	1	6	Deep and general anesthesia, moderate sedation:  initial increment limited to 1 per day; additional increments covered as medically necessary. Adjunctive drug administration services limited to 1 per day.	2				2				1	2
H3113	005	0	1	01	01	H3113_005_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3113	009	0	1	02	01	H3113_009_0	4	2				1	30	30	30	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3113	010	0	1	02	01	H3113_010_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3113	014	0	1	02	01	H3113_014_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3113	016	0	1	02	01	H3113_016_0	4	2				1	30	30	30	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3124	003	0	1	04	01	H3124_003_0	12	2				2				1	45.00	45.00	45.00	2		2	2	1	2	550.00	3		1	1	2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H3127	001	0	1	01	01	H3127_001_0	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3146	001	0	1	01	01	H3146_001_0	4	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	002	0	1	01	01	H3146_002_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3146	004	0	1	01	01	H3146_004_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	006	0	1	01	01	H3146_006_0	4	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	007	0	1	01	01	H3146_007_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	011	0	1	01	01	H3146_011_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	012	0	1	01	01	H3146_012_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	014	0	1	01	01	H3146_014_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	016	0	1	01	01	H3146_016_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3146	022	0	1	01	01	H3146_022_0	4	2				1	20	20	20	2				2		1	2	1		500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3146	023	0	1	01	01	H3146_023_0	4	2				1	20	20	20	2				2		1	2	1		500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3146	036	0	1	01	01	H3146_036_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3146	037	0	1	01	01	H3146_037_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	038	0	1	01	01	H3146_038_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	039	0	1	01	01	H3146_039_0	4	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	040	0	1	01	01	H3146_040_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	044	0	1	01	01	H3146_044_0	4	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	047	0	1	01	01	H3146_047_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	048	0	1	01	01	H3146_048_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	049	0	1	01	01	H3146_049_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	050	0	1	01	01	H3146_050_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1750.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	051	0	1	01	01	H3146_051_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	052	0	1	01	01	H3146_052_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	053	0	1	01	01	H3146_053_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	056	0	1	02	01	H3146_056_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	057	0	1	02	01	H3146_057_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	058	0	1	01	01	H3146_058_0	4	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	059	0	1	01	01	H3146_059_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	060	0	1	01	01	H3146_060_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3146	801	0	1	01	01	H3146_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3152	022	0	1	02	01	H3152_022_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3152	045	0	1	01	01	H3152_045_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3152	048	0	1	01	01	H3152_048_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3152	080	0	1	02	01	H3152_080_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3152	082	0	1	01	01	H3152_082_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3152	098	0	1	01	01	H3152_098_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3152	801	0	1	01	01	H3152_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3152	804	0	1	01	01	H3152_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3152	807	0	1	01	01	H3152_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3170	004	0	1	02	01	H3170_004_0	7	2				2				1	45.00	45.00	45.00	2		2	2	1		500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2																																																																																																																																																																					
H3186	001	0	1	04	01	H3186_001_0	11	2				2				1	45.00	45.00	45.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																																																																																																																																																																																				
H3186	002	0	1	04	01	H3186_002_0	11	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																																																																																																																																																																																				
H3192	001	0	1	02	01	H3192_001_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	003	0	1	02	01	H3192_003_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	005	0	1	02	01	H3192_005_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3192	007	0	1	01	01	H3192_007_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3192	010	0	1	02	01	H3192_010_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	013	0	1	02	01	H3192_013_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	020	0	1	02	01	H3192_020_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3192	028	0	1	01	01	H3192_028_0	3	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3192	029	0	1	01	01	H3192_029_0	3	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3192	033	0	1	01	01	H3192_033_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	036	0	1	01	01	H3192_036_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	037	0	1	01	01	H3192_037_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	801	0	1	01	01	H3192_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3204	013	4	1	01	01	H3204_013_4	5	2				1	20	20	20	2				2		2	2	1		3000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	4	3		2				2				2	2	2	2	99	6	Dentures limited to every 5 years.	2				2				2	2	2	1				2				2				2	2																2	2	99	6	Dentures limited to every 5 years.	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3204	013	5	1	01	01	H3204_013_5	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3204	013	6	1	01	01	H3204_013_6	5	2				1	20	20	20	2				2		2	2	1		1800.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	4	3		2				2				2	2	2	2	99	6	Dentures limited to every 5 years.	2				2				2	2	2	1				2				2				2	2																2	2	99	6	Dentures limited to every 5 years.	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3204	801	0	1	01	01	H3204_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3204	802	0	1	01	01	H3204_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3204	803	0	1	01	01	H3204_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3204	808	0	1	02	01	H3204_808_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3204	809	0	1	02	01	H3204_809_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3204	810	0	1	02	01	H3204_810_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3219	001	0	1	04	01	H3219_001_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1300.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3219	002	0	1	04	01	H3219_002_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1600.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3219	003	0	1	04	01	H3219_003_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2																															2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2																2	1				1	30	30	30	2				2	2
H3219	004	0	1	04	01	H3219_004_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2100.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3219	005	0	1	04	01	H3219_005_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2100.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3219	008	0	1	04	01	H3219_008_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2050.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3219	015	0	1	04	01	H3219_015_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3219	016	0	1	04	01	H3219_016_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3219	801	0	1	04	01	H3219_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3239	001	0	1	01	01	H3239_001_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	002	0	1	01	01	H3239_002_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	005	0	1	01	01	H3239_005_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	010	0	1	01	01	H3239_010_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1200.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	012	0	1	01	01	H3239_012_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	014	0	1	01	01	H3239_014_0	3	2				2				1	49.00	49.00	49.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3239	015	0	1	01	01	H3239_015_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	017	0	1	01	01	H3239_017_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3239	020	0	1	01	01	H3239_020_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3239	022	0	1	01	01	H3239_022_0	3	2				2				1	54.00	54.00	54.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3239	023	0	1	01	01	H3239_023_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	026	0	1	01	01	H3239_026_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	027	0	1	01	01	H3239_027_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	028	0	1	01	01	H3239_028_0	3	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	030	0	1	01	01	H3239_030_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3239	031	0	1	01	01	H3239_031_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3240	013	0	1	01	01	H3240_013_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3240	017	0	1	02	01	H3240_017_0	5	2				1	20	20	20	2				2		1	2	1		1200.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3240	026	0	1	01	01	H3240_026_0	5	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																						
H3256	004	1	1	04	01	H3256_004_1	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3256	004	2	1	04	01	H3256_004_2	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3256	005	1	1	04	01	H3256_005_1	4	2				1	20	20	20	2				2		1	2	1	2	1250.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3256	005	2	1	04	01	H3256_005_2	4	2				1	20	20	20	2				2		1	2	1	2	1250.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3256	006	1	1	04	01	H3256_006_1	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3256	006	2	1	04	01	H3256_006_2	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3256	006	3	1	04	01	H3256_006_3	4	2				1	20	20	20	2				2		1	2	1	2	750.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3256	801	0	1	04	01	H3256_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3256	802	0	1	04	01	H3256_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3259	001	0	1	01	01	H3259_001_0	9	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	2				2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	2				2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	2				2				2	2
H3259	002	0	1	01	01	H3259_002_0	8	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	2				2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	2				2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	2				2				2	2
H3259	003	0	1	01	01	H3259_003_0	9	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	2				2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	2				2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	2				2				2	2
H3274	001	0	1	01	01	H3274_001_0	8	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3274	002	0	1	01	01	H3274_002_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3274	005	0	1	01	01	H3274_005_0	7	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2200.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3284	001	0	1	20	08	H3284_001_0	1																																																																																																																																																																																																																																																																																																						
H3284	002	0	1	20	08	H3284_002_0	1																																																																																																																																																																																																																																																																																																						
H3288	001	0	1	04	01	H3288_001_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	002	0	1	04	01	H3288_002_0	5	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	003	0	1	04	01	H3288_003_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	004	0	1	04	01	H3288_004_0	5	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	005	0	1	04	01	H3288_005_0	3	2				2				1	70.00	70.00	70.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3288	006	0	1	04	01	H3288_006_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3288	007	0	1	04	01	H3288_007_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	008	0	1	04	01	H3288_008_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	009	0	1	04	01	H3288_009_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	011	0	1	04	01	H3288_011_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3288	017	0	1	04	01	H3288_017_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	018	0	1	04	01	H3288_018_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3288	019	0	1	04	01	H3288_019_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	020	0	1	04	01	H3288_020_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	027	0	1	04	01	H3288_027_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	034	0	1	04	01	H3288_034_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	042	0	1	04	01	H3288_042_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	046	0	1	04	01	H3288_046_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3288	047	0	1	04	01	H3288_047_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	048	0	1	04	01	H3288_048_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3288	051	0	1	04	01	H3288_051_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3288	053	0	1	04	01	H3288_053_0	3	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H3288	801	0	1	04	01	H3288_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3291	001	0	1	01	01	H3291_001_0	6	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3291	002	0	1	01	01	H3291_002_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3291	003	0	1	01	01	H3291_003_0	4	2				2				2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the notes for periodicity.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3305	007	0	1	02	01	H3305_007_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		300.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3305	015	0	1	02	01	H3305_015_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		300.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3305	020	0	1	02	01	H3305_020_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3305	022	0	1	02	01	H3305_022_0	8	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		300.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3305	033	0	1	01	01	H3305_033_0	6	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	1 to 3 times every 6 to 12 months depending on type of service. Some services have a lifetime limitation.	2				2				2	2	2	2	1	6	1 to 3 times every 1 week to 36 months depending on type of service. Some services have a lifetime limitation.	2				2				1	2	2	2	1	6	1 to 3 times every 1 week to 36 months depending on type of service. Some services have a lifetime limitation.	2				2				1	2	2	2	2	6	Every 12 to 36 months depending on type of service.	2				2				2	2	2	2	1	6	Every 6 to 12 months depending on type of service.	2				2				2	2	2	1				2				2				1	2	2								2					2		2	2	1	6	Every 12 to 60 months depending on type of service.	2				2				1	2	2	2	1	6	1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	Every 6 to 24 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 4 times every 12 to 96 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 6 times every 2 to 12 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	12 to 96 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	24 to 60 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 3 times every 6 to 60 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2																2	2	1	6	1 to 4 times every 1 day to 12 months depending on type of service.	2				2				1	2
H3305	034	0	1	01	01	H3305_034_0	7	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	1 to 3 times every 6 to 12 months depending on type of service. Some services have a lifetime limitation.	2				2				2	2	2	2	1	6	1 to 3 times every 1 week to 36 months depending on type of service. Some services have a lifetime limitation.	2				2				1	2	2	2	1	6	1 to 3 times every 1 week to 36 months depending on type of service. Some services have a lifetime limitation.	2				2				1	2	2	2	2	6	Every 12 to 36 months depending on type of service.	2				2				2	2	2	2	1	6	Every 6 to 12 months depending on type of service.	2				2				2	2	2	1				2				2				1	2	2								2					2		2	2	1	6	Every 12 to 60 months depending on type of service.	2				2				1	2	2	2	1	6	1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	Every 6 to 24 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 4 times every 12 to 96 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 6 times every 2 to 12 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	12 to 96 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	24 to 60 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 3 times every 6 to 60 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2																2	2	1	6	1 to 4 times every 1 day to 12 months depending on type of service.	2				2				1	2
H3305	038	0	1	02	01	H3305_038_0	8	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3305	039	0	1	02	01	H3305_039_0	8	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3305	801	0	1	02	01	H3305_801_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3305	803	0	1	02	01	H3305_803_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3305	804	0	1	02	01	H3305_804_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3312	002	0	1	01	01	H3312_002_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3312	018	0	1	02	01	H3312_018_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3312	048	0	1	01	01	H3312_048_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3312	064	0	1	01	01	H3312_064_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3312	065	0	1	02	01	H3312_065_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		750.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3312	069	0	1	01	01	H3312_069_0	3	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2
H3312	070	0	1	01	01	H3312_070_0	3	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2
H3312	073	0	1	01	01	H3312_073_0	4	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2
H3312	074	0	1	01	01	H3312_074_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3312	081	0	1	01	01	H3312_081_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3312	091	0	1	01	01	H3312_091_0	3	2				2				1	60.00	60.00	60.00	2		1	2	1		750.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3312	097	0	1	01	01	H3312_097_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3312	105	0	1	01	01	H3312_105_0	3	2				2				1	55.00	55.00	55.00	2		1	2	1		750.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3312	107	0	1	01	01	H3312_107_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3312	108	0	1	01	01	H3312_108_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3312	111	0	1	01	01	H3312_111_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3312	112	0	1	01	01	H3312_112_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3312	113	0	1	01	01	H3312_113_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3312	801	0	1	01	01	H3312_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3312	804	0	1	01	01	H3312_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3312	807	0	1	01	01	H3312_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3321	001	0	1	20	08	H3321_001_0	1																																																																																																																																																																																																																																																																																																						
H3321	003	0	1	20	08	H3321_003_0	1																																																																																																																																																																																																																																																																																																						
H3322	001	0	1	20	08	H3322_001_0	1																																																																																																																																																																																																																																																																																																						
H3322	002	0	1	20	08	H3322_002_0	1																																																																																																																																																																																																																																																																																																						
H3329	001	0	1	20	08	H3329_001_0	1																																																																																																																																																																																																																																																																																																						
H3329	002	0	1	20	08	H3329_002_0	1																																																																																																																																																																																																																																																																																																						
H3330	021	2	1	01	01	H3330_021_2	9	2				2				2				2		2	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2								2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	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 month	2				3		0.00	150.00	1	2	2	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	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	021	3	1	01	01	H3330_021_3	9	2				2				2				2		2	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2								2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	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 month	2				3		0.00	150.00	1	2	2	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	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	021	5	1	01	01	H3330_021_5	9	2				2				2				2		2	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2								2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	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 month	2				3		0.00	150.00	1	2	2	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	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	038	0	1	01	01	H3330_038_0	9	2				2				2				2		2	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2								2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	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	2				3		0.00	150.00	1	2	2	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	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	049	0	1	01	01	H3330_049_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2								2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	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 month	2				3		0.00	150.00	1	2	2	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	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	050	0	1	01	01	H3330_050_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2								2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	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 month	2				3		0.00	150.00	1	2	2	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	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	051	0	1	01	01	H3330_051_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2								2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	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 month	2				3		0.00	150.00	1	2	2	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	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	052	0	1	01	01	H3330_052_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2								2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	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 month	2				3		0.00	150.00	1	2	2	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	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	814	0	1	01	01	H3330_814_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3330	815	0	1	01	01	H3330_815_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3330	820	0	1	02	01	H3330_820_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3330	821	0	1	02	01	H3330_821_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3331	001	0	1	20	08	H3331_001_0	2																																																																																																																																																																																																																																																																																																						
H3331	002	0	1	20	08	H3331_002_0	2																																																																																																																																																																																																																																																																																																						
H3335	801	0	1	04	01	H3335_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3335	811	0	1	04	01	H3335_811_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3335	813	0	1	04	01	H3335_813_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3335	819	0	1	04	01	H3335_819_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3335	820	0	1	04	01	H3335_820_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3335	822	0	1	04	01	H3335_822_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3335	824	0	1	04	01	H3335_824_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3335	825	0	1	04	01	H3335_825_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3344	013	0	1	04	01	H3344_013_0	8	2				2				3		40.00	450.00	2		1	2	1	2	1500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3344	801	0	1	04	01	H3344_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3344	804	0	1	04	01	H3344_804_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3344	805	0	1	04	01	H3344_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3347	002	0	1	02	01	H3347_002_0	8	2				1	20	20	20	2				2		2	2	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	1	6	Oral Exams: $0 copayment select codes. 1 every month,  6 months,  90 days, and 10 days	2								2	2	2	2	1	6	X Rays: $0 copay for select codes. $0 copay for  1 every 6,  12 or 36 months. Select codes covered 1 every month. 2 every week, 2 every  6 months, 2 every 12 months  3 every 6 or 12 months. Select codes covered 1 every 10 days. 1 every 90 days.	2								2	2	2	2	1	6	Other Diagnostic Services: $0 copay for select codes.	2								2	2	2	2	1	4		2								2	2	2	2	1	6	$0 copay for select codes.  $0 copay for 1 every 3 months, 4 every 12 months	2								2	2	2	2	1	6	Other Preventive Services: $0 copay for select codes.	2								2	2	2								2					2		2	2	1	6	Coverage is limited to select codes. Restorative:  $0 copay /1 every 12, 24, or 60 Mo Select codes $0 copay /2 every 12 Mo Select codes are covered at $0 copay.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic ServicesSelect Codes Only at $0 copayment /1 per lifetime. Select codes are covered at $0 copay	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodontics Services: Select Codes Only at $0 copayment /1 every 6, 12, 24, or 60 months. Select codes only at $0 Copayment/ 1 per lifetime. Select codes are covered at $0 copay.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Select Codes Only at $0 copayment /1 every 12, 24, 60, 96 months. $0 copayment  / 2 every 12 months. $0 copayment 4 every 12 months. Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Maxillofacial Prosthetics services Select Codes Only at $0 copayment  1 every 6 or 12 months / 2 every 12 months. / 6 every 2 months.Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Select Codes only at $0 copayment every 12 months and every 2 years. $0 copayment for 1 every 8 years. $0 copayment for 1 per lifetime.Select codes are covered at $0 copayment	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics, fixed services Select Codes Only at $0 copayment /1 every 60 months. $0 copayment  / 1 every 24 months. Select codes are covered at $0 copayment	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Select Codes Only at $0 copay / 1 every 6 or 12 months/ 1 every 24 months. 2 every  60 months. $0 copay  / 1 every lifetime. $0 copay / 2 every lifetime. $0 copay / 3 every lifetime. Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Adjunctive General ServicesSelect Codes Only at $0 copayment /1 every 6 or 12 months. $0 copayment  / 2 every 12 months. Select codes are covered at $0 copayment. $0 copayment/ 1 every 7 days. $0 copayment 1 every date of service.  $0 copayment 3 every date of service	2				1	0.00	0.00	0.00	1	2
H3347	003	0	1	02	01	H3347_003_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3347	007	0	1	02	01	H3347_007_0	10	2				1	20	20	20	2				2		2	2	2							2				2					1	111111	0.00	0.00	0.00	2		2	2	1	6	Oral Exams: $0 copayment select codes. 1 every month,  6 months,  90 days, and 10 days	2								2	2	2	2	1	6	X Rays: $0 copay for select codes. $0 copay for  1 every 6,  12 or 36 months. Select codes covered 1 every month. 2 every week, 2 every  6 months, 2 every 12 months  3 every 6 or 12 months. Select codes covered 1 every 10 days. 1 every 90 days.	2								2	2	2	2	1	6	Other Diagnostic Services: $0 copay for select codes.	2								2	2	2	2	1	4		2								2	2	2	2	1	6	$0 copay for select codes.  $0 copay for 1 every 3 months, 4 every 12 months	2								2	2	2	2	1	6	Other Preventive Services: $0 copay for select codes.	2								2	2	2								2					2		2	2	1	6	Coverage is limited to select codes. Restorative:  $0 copay /1 every 12, 24, or 60 Mo Select codes $0 copay /2 every 12 Mo Select codes are covered at $0 copay.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic ServicesSelect Codes Only at $0 copayment /1 per lifetime. Select codes are covered at $0 copay	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodontics Services: Select Codes Only at $0 copayment /1 every 6, 12, 24 or 60 months. Select codes only at $0 Copayment/ 1 per lifetime. Select codes are covered at $0 copay.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Select Codes Only at $0 copayment /1 every 12, 24, 60, 96 months. $0 copayment  / 2 every 12 months. $0 copayment 4 every 12 months. Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Maxillofacial Prosthetics services Select Codes Only at $0 copayment  1 every 6 or 12 months. / 2 every 12 months. / 6 every 2 months.Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Select Codes only at $0 copayment every 12 months and every 2 years. $0 copayment for 1 every 8 years. $0 copayment for 1 per lifetime.Select codes are covered at $0 copayment	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics, fixed services Select Codes Only at $0 copayment /1 every 60 months. $0 copayment  / 1 every 24 months. Select codes are covered at $0 copayment	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Select Codes Only at $0 copay / 1 every 6 or 12 months/ 1 every 24 months. 2 every  60 months. $0 copay  / 1 every lifetime. $0 copay / 2 every lifetime. $0 copay / 3 every lifetime. Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Adjunctive General ServicesSelect Codes Only at $0 copayment /1 every 6 or 12 months. $0 copayment  / 2 every 12 months. Select codes are covered at $0 copayment. $0 copayment/ 1 every 7 days. $0 copayment 1 every date of service.  $0 copayment 3 every date of service	2				1	0.00	0.00	0.00	1	2
H3347	018	0	1	02	01	H3347_018_0	10	2				1	20	20	20	2				2		2	2	1		1950.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2
H3351	001	0	1	02	01	H3351_001_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		500.00	3		2		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3351	002	0	1	02	01	H3351_002_0	6	2				2				1	25.00	25.00	25.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		500.00	3		2		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3351	006	0	1	02	01	H3351_006_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		500.00	3		2		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3351	007	0	1	02	01	H3351_007_0	4	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3351	012	0	1	02	01	H3351_012_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		500.00	3		2		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3351	017	0	1	01	01	H3351_017_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		500.00	3		2		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3351	019	0	1	02	01	H3351_019_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		500.00	3		2		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3351	022	0	1	01	01	H3351_022_0	6	2				2				1	60.00	60.00	60.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3351	023	0	1	02	01	H3351_023_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3351	024	0	1	01	01	H3351_024_0	5	2				2				1	55.00	55.00	55.00	2		2	2	2							2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																																																			
H3351	025	0	1	02	01	H3351_025_0	5	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3351	026	0	1	02	01	H3351_026_0	5	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3351	027	0	1	02	01	H3351_027_0	4	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3351	028	0	1	01	01	H3351_028_0	5	2				2				1	55.00	55.00	55.00	2		2	2	2							2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																																																			
H3351	029	0	1	02	01	H3351_029_0	5	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3351	030	0	1	02	01	H3351_030_0	5	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3351	031	0	1	02	01	H3351_031_0	4	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3351	032	0	1	02	01	H3351_032_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3351	033	0	1	02	01	H3351_033_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3351	801	0	1	02	01	H3351_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3351	802	0	1	02	01	H3351_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3351	803	0	1	02	01	H3351_803_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3351	804	0	1	02	01	H3351_804_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3351	805	0	1	02	01	H3351_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3351	806	0	1	02	01	H3351_806_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3359	001	0	1	01	01	H3359_001_0	11	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	1	6	Limits vary by procedure.	2				1	45.00	45.00	45.00	1	2	2	2	1	6	Limits vary by procedure.	2				1	45.00	45.00	45.00	1	2	2	2	1	6	Limits vary by procedure.	2				1	45.00	45.00	45.00	1	2	2	2	1	6	Limits vary by procedure.	2				1	45.00	45.00	45.00	1	2	2	1				2				1	45.00	45.00	45.00	1	2																2	2	1	6	Limits vary by procedure.	2				1	45.00	45.00	45.00	1	2	2	2	1	6	Limits vary by procedure.	2				1	45.00	45.00	45.00	1	2																2	2	1	6	Limits vary by procedure.	2				1	45.00	45.00	45.00	1	2
H3359	019	0	1	01	01	H3359_019_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	2		1500.00	3		2		2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2
H3359	021	0	1	01	01	H3359_021_0	10	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				2	2	2								2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2
H3359	034	0	1	01	01	H3359_034_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	6	Limits vary by procedure	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				2	2	2								2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2
H3359	038	0	1	01	01	H3359_038_0	10	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				2	2	2								2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2
H3359	808	0	1	01	01	H3359_808_0	1	2				2				2				2		1	2																																																																																																																																																																																																																																																																																						
H3359	809	0	1	01	01	H3359_809_0	1	2				2				2				2		1	2																																																																																																																																																																																																																																																																																						
H3362	016	0	1	01	01	H3362_016_0	6	2				2				3		30.00	300.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3362	020	0	1	01	01	H3362_020_0	8	2				2				3		0.00	400.00	2		1	2																																																																																																																																																																																																																																																																																						
H3362	040	0	1	01	01	H3362_040_0	7	2				1	20	20	20	3		25.00	115.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3362	042	0	1	01	01	H3362_042_0	8	2				2				3		40.00	500.00	2		1	2	1		1500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3362	044	0	1	01	01	H3362_044_0	8	2				2				3		35.00	400.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3362	045	0	1	01	01	H3362_045_0	7	2				2				3		25.00	375.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3362	801	0	1	01	01	H3362_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3362	807	0	1	02	01	H3362_807_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3362	819	0	1	02	01	H3362_819_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3362	820	0	1	01	01	H3362_820_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3379	001	0	1	02	01	H3379_001_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3379	039	0	1	02	01	H3379_039_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3379	040	0	1	02	01	H3379_040_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3379	052	0	1	02	01	H3379_052_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3379	053	0	1	02	01	H3379_053_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3379	054	0	1	02	01	H3379_054_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3379	056	0	1	02	01	H3379_056_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3379	059	0	1	02	01	H3379_059_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3379	060	0	1	02	01	H3379_060_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3379	061	0	1	02	01	H3379_061_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3379	802	0	1	01	01	H3379_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3379	803	0	1	01	01	H3379_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3379	804	0	1	01	01	H3379_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3384	013	0	1	01	01	H3384_013_0	9	2				2				1	35.00	35.00	35.00	2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.  Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	022	0	1	01	01	H3384_022_0	7	2				2				1	45.00	45.00	45.00	2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	069	1	1	01	01	H3384_069_1	12	2				2				1	55.00	55.00	55.00	2		2	2	1		1000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.  Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	069	2	1	01	01	H3384_069_2	10	2				2				1	60.00	60.00	60.00	2		2	2	1		750.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.  Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	069	3	1	01	01	H3384_069_3	12	2				2				1	60.00	60.00	60.00	2		2	2	1		500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.  Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	070	1	1	01	01	H3384_070_1	9	2				2				1	40.00	40.00	40.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.  Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	070	2	1	01	01	H3384_070_2	9	2				2				1	40.00	40.00	40.00	2		2	2	1		1000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.  Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	070	3	1	01	01	H3384_070_3	9	2				2				1	45.00	45.00	45.00	2		2	2	1		1000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.  Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	072	0	1	01	01	H3384_072_0	7	2				2				1	75.00	75.00	75.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																				
H3384	073	1	1	01	01	H3384_073_1	8	2				2				1	25.00	25.00	25.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.  Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	073	2	1	01	01	H3384_073_2	7	2				2				1	25.00	25.00	25.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.  Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	073	3	1	01	01	H3384_073_3	7	2				2				1	25.00	25.00	25.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.  Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	805	0	1	01	01	H3384_805_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3384	806	0	1	01	01	H3384_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3384	811	0	1	02	01	H3384_811_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3384	812	0	1	02	01	H3384_812_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3384	813	0	1	01	01	H3384_813_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3387	013	0	1	02	01	H3387_013_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	014	1	1	02	01	H3387_014_1	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	014	2	1	02	01	H3387_014_2	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	014	3	1	02	01	H3387_014_3	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	014	4	1	02	01	H3387_014_4	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	014	5	1	02	01	H3387_014_5	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	014	6	1	02	01	H3387_014_6	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	015	1	1	02	01	H3387_015_1	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	015	2	1	02	01	H3387_015_2	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	017	0	1	02	01	H3387_017_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3388	001	0	1	01	01	H3388_001_0	5	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3388	002	0	1	01	01	H3388_002_0	8	2				2				1	35.00	35.00	35.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3388	014	0	1	01	01	H3388_014_0	9	2				2				1	50.00	50.00	50.00	2		2	2	1		400.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3388	020	0	1	01	01	H3388_020_0	8	2				2				1	40.00	40.00	40.00	2		2	2	1		900.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3388	801	0	1	01	01	H3388_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3388	803	0	1	01	01	H3388_803_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3388	804	0	1	01	01	H3388_804_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3404	003	1	1	04	01	H3404_003_1	9	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	See detailed note below.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed note below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Complete and partial dentures covered 1 per arch every 60 months.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	Surgical procedures covered once every 60 monthsAlveoloplasty covered once every 60 monthsFrenulectomy, frenectomy or frenotomy (separate procedures) covered once every 60 months	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed notes below.	2				1	0.00	0.00	0.00	2	2
H3404	003	2	1	04	01	H3404_003_2	8	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	See detailed note below.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed note below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Complete and partial dentures covered 1 per arch every 60 months.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	Surgical procedures covered once every 60 monthsAlveoloplasty covered once every 60 monthsFrenulectomy, frenectomy or frenotomy (separate procedures) covered once every 60 months	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed notes below.	2				1	0.00	0.00	0.00	2	2
H3404	004	0	1	04	01	H3404_004_0	7	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3404	801	0	1	04	01	H3404_801_0	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3404	810	0	1	04	01	H3404_810_0	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3404	811	0	1	04	01	H3404_811_0	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3407	001	0	1	01	01	H3407_001_0	8	2				2				2				2		2	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	2	1	6	restorative fillings one per surface per tooth every 2 years.   Restorative Inlay/Onlay one per tooth every 5 years. Restorative crowns is one per tooth every 5 years. Restorative repair is unlimited.	2				2				1	2	2	2	1	6	Endodontics one per tooth per lifetime.	2				2				2	2	2	2	1	6	Periodontal root planning and scaling one per quadrant every 2 years. Periodontal surgical services one per quadrant every 3 years.	2				2				1	2	2	2	1	6	Prosthodontics (dentures) one set every 5 years. Denture adjustments/repair one per arch every year. Denture reline one per arch every 2 years.	2				2				1	2																2	2	1	6	Implants 1 per tooth every 5 years.	2				2				1	2	2	2	1	6	Fixed partial dentures (bridges) one per tooth every 5 years.	2				2				1	2	2	2	1	6	Surgical extractions one per site/quadrant per lifetime.	2				2				1	2																2	2	1	6	Occusal guards one every 3 years. Tele-dentistry 2 every year.	2				2				1	2
H3407	002	0	1	01	01	H3407_002_0	5	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Restorative fillings one per surface per tooth every 2 years. Restorative inlay/onlay 1 per tooth every 5 years. Restorative crowns one per tooth every 5 years. Restorative repair unlimited.	2				2				2	2	2	2	1	6	Endodontics 1 per tooth per lifetime	2				2				1	2	2	2	1	6	Periodontal Root Planning and Scaling, one per site/quadrant every 2 years. Periodontal Surgical Services, one per site/quadrant every 5 years.	2				2				2	2	2	2	1	6	Prosthodontics (Dentures) one set every 5 years. Denture adjustments/repair 1 per arch every year. Denture reline, one per arch every 2 years.	2				2				2	2																															2	2	1	6	Fixed partial denture (bridges) one per tooth every five years.	2				2				2	2	2	2	1	6	Surgical extractions 1 per site/quadrant per lifetime.	2				2				2	2																2	2	1	6	Occusal guards 1 every 3 years. Teledentistry 2 every year.	2				2				2	2
H3407	003	0	1	01	01	H3407_003_0	5	2				2				1	35.00	35.00	35.00	2		2	2	1		750.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3407	004	0	1	01	01	H3407_004_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	2	1	6	restorative fillings one per surface per tooth every 2 years.   Restorative Inlay/Onlay one per tooth every 5 years. Restorative crowns is one per tooth every 5 years. Restorative repair is unlimited.	2				2				1	2	2	2	1	6	Endodontics one per tooth per lifetime.	2				2				2	2	2	2	1	6	Periodontal root planning and scaling one per quadrant every 2 years. Periodontal surgical services one per quadrant every 3 years.	2				2				1	2	2	2	1	6	Prosthodontics (dentures) one set every 5 years. Denture adjustments/repair one per arch every year. Denture reline one per arch every 2 years.	2				2				1	2																2	2	1	6	Implants 1 per tooth every 5 years.	2				2				1	2	2	2	1	6	Fixed partial dentures (bridges) one per tooth every 5 years.	2				2				1	2	2	2	1	6	Surgical extractions one per site/quadrant per lifetime.	2				2				1	2																2	2	1	6	Occusal guards one every 3 years. Tele-dentistry 2 every year.	2				2				1	2
H3418	001	0	1	04	01	H3418_001_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3418	002	0	1	04	01	H3418_002_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3418	004	0	1	04	01	H3418_004_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3418	008	0	1	04	01	H3418_008_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3418	801	0	1	04	01	H3418_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3419	001	0	1	01	01	H3419_001_0	7	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2300.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3419	003	0	1	02	01	H3419_003_0	10	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3419	004	0	1	02	01	H3419_004_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		8500.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3419	005	0	1	01	01	H3419_005_0	9	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3419	006	0	1	01	01	H3419_006_0	8	2				1	20	20	20	2				2		1	2	1		2100.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2
H3419	007	0	1	01	01	H3419_007_0	9	2				1	20	20	20	2				2		1	2	1		2100.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3430	001	0	1	20	08	H3430_001_0	1																																																																																																																																																																																																																																																																																																						
H3430	002	0	1	20	08	H3430_002_0	1																																																																																																																																																																																																																																																																																																						
H3443	001	0	1	01	01	H3443_001_0	9	2				2				2				2		1	2	2							2				2					2					2		2	1				2				1	10.00	10.00	10.00	1	2	2	1				2				1	30.00	30.00	30.00	1	2																2	1				2				1	20.00	20.00	20.00	1	2	2	1				2				1	10.00	10.00	10.00	1	2																1	2		2000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3443	002	0	1	01	01	H3443_002_0	10	2				2				2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3443	003	0	1	01	01	H3443_003_0	9	2				2				2				2		1	2	2							2				2					2					2		2	1				2				1	10.00	10.00	10.00	1	2	2	1				2				1	30.00	30.00	30.00	1	2																2	1				2				1	20.00	20.00	20.00	1	2	2	1				2				1	10.00	10.00	10.00	1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	350.00	1	2	2	1				2				3		15.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		25.00	250.00	1	2																														
H3443	005	0	1	01	01	H3443_005_0	9	2				2				2				2		1	2	2							2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																																																																																																																																																																																				
H3443	006	0	1	01	01	H3443_006_0	9	2				1	20	20	20	2				2		1	2	1		3700.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3443	007	0	1	01	01	H3443_007_0	10	2				2				2				2		1	2	1		2400.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3443	008	0	1	01	01	H3443_008_0	9	2				2				2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3443	801	0	1	01	01	H3443_801_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H3443	802	0	1	01	01	H3443_802_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H3443	803	0	1	01	01	H3443_803_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H3443	804	0	1	01	01	H3443_804_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H3447	013	0	1	02	01	H3447_013_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H3447	018	0	1	01	01	H3447_018_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3447	024	0	1	02	01	H3447_024_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	025	0	1	02	01	H3447_025_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H3447	033	0	1	02	01	H3447_033_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1800.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3447	037	0	1	02	01	H3447_037_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3447	038	1	1	02	01	H3447_038_1	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	038	2	1	02	01	H3447_038_2	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	039	0	1	02	01	H3447_039_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	042	1	1	02	01	H3447_042_1	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	042	2	1	02	01	H3447_042_2	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	042	3	1	02	01	H3447_042_3	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	042	4	1	02	01	H3447_042_4	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H3447	049	0	1	02	01	H3447_049_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1750.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	050	0	1	02	01	H3447_050_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	051	0	1	02	01	H3447_051_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	052	0	1	02	01	H3447_052_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2600.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	053	0	1	01	01	H3447_053_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3447	056	0	1	02	01	H3447_056_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3447	804	0	1	01	01	H3447_804_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	805	0	1	01	01	H3447_805_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	806	0	2	01	01	H3447_806_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	807	0	2	01	01	H3447_807_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	809	0	1	01	01	H3447_809_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	811	0	1	01	01	H3447_811_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	812	0	1	01	01	H3447_812_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	813	0	2	01	01	H3447_813_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	814	0	2	01	01	H3447_814_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	816	0	1	01	01	H3447_816_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	818	0	1	01	01	H3447_818_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	819	0	1	01	01	H3447_819_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	820	0	2	01	01	H3447_820_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	821	0	2	01	01	H3447_821_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	823	0	1	01	01	H3447_823_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	825	0	2	01	01	H3447_825_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	826	0	2	01	01	H3447_826_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	827	0	2	01	01	H3447_827_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3447	828	0	1	01	01	H3447_828_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3449	012	0	1	02	01	H3449_012_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	023	1	1	02	01	H3449_023_1	8	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2																																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																											2	2	1	6	Palliative treatment/minor procedure covered once every calendar year.  Teledentistry covered twice every calendar year.	2				1	0.00	0.00	0.00	2	2
H3449	023	2	1	02	01	H3449_023_2	8	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2																																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																											2	2	1	6	Palliative treatment/minor procedure covered once every calendar year.  Teledentistry covered twice every calendar year.	2				1	0.00	0.00	0.00	2	2
H3449	023	4	1	02	01	H3449_023_4	9	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2																																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																											2	2	1	6	Palliative treatment/minor procedure covered once every calendar year.  Teledentistry covered twice every calendar year.	2				1	0.00	0.00	0.00	2	2
H3449	023	5	1	02	01	H3449_023_5	7	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2																																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																											2	2	1	6	Palliative treatment/minor procedure covered once every calendar year.  Teledentistry covered twice every calendar year.	2				1	0.00	0.00	0.00	2	2
H3449	024	1	1	02	01	H3449_024_1	8	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	024	2	1	02	01	H3449_024_2	9	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	024	3	1	02	01	H3449_024_3	8	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	027	1	1	01	01	H3449_027_1	8	2				2				1	50.00	50.00	50.00	2		1	2																																																																																																																																																																																																																																																																																						
H3449	027	2	1	01	01	H3449_027_2	8	2				2				1	50.00	50.00	50.00	2		1	2																																																																																																																																																																																																																																																																																						
H3449	805	0	1	01	01	H3449_805_0	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3449	814	0	1	01	01	H3449_814_0	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3449	815	0	1	01	01	H3449_815_0	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3467	001	0	1	02	01	H3467_001_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		480.00	3		2		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3467	002	0	1	02	01	H3467_002_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2000.00	3		2		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3467	005	0	1	02	01	H3467_005_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2300.00	3		2		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3473	001	0	1	20	08	H3473_001_0	1																																																																																																																																																																																																																																																																																																						
H3473	002	0	1	20	08	H3473_002_0	1																																																																																																																																																																																																																																																																																																						
H3493	001	0	1	20	08	H3493_001_0	1																																																																																																																																																																																																																																																																																																						
H3493	002	0	1	20	08	H3493_002_0	1																																																																																																																																																																																																																																																																																																						
H3499	002	0	1	02	01	H3499_002_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H3515	001	0	1	01	01	H3515_001_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2750.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H3515	002	0	1	01	01	H3515_002_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H3515	003	0	1	01	01	H3515_003_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H3515	004	0	1	01	01	H3515_004_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H3515	005	0	1	01	01	H3515_005_0	4	2				1	30	30	30	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H3515	006	0	1	01	01	H3515_006_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		2750.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H3515	007	0	1	01	01	H3515_007_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H3515	008	0	1	01	01	H3515_008_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H3515	009	0	1	01	01	H3515_009_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		3000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H3515	010	0	1	01	01	H3515_010_0	3	2				1	30	30	30	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H3515	011	0	1	01	01	H3515_011_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		1250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H3515	012	0	1	01	01	H3515_012_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H3515	013	0	1	01	01	H3515_013_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H3515	014	0	1	01	01	H3515_014_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H3515	015	0	1	01	01	H3515_015_0	4	2				1	30	30	30	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H3515	020	0	1	01	01	H3515_020_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		3000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H3515	021	0	1	01	01	H3515_021_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H3515	022	0	1	01	01	H3515_022_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H3517	001	0	1	20	08	H3517_001_0	1																																																																																																																																																																																																																																																																																																						
H3517	002	0	1	20	08	H3517_002_0	1																																																																																																																																																																																																																																																																																																						
H3522	001	0	1	20	08	H3522_001_0	1																																																																																																																																																																																																																																																																																																						
H3522	002	0	1	20	08	H3522_002_0	1																																																																																																																																																																																																																																																																																																						
H3529	001	1	1	02	01	H3529_001_1	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3529	001	2	1	02	01	H3529_001_2	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3529	001	3	1	02	01	H3529_001_3	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3529	001	4	1	02	01	H3529_001_4	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3529	002	1	1	02	01	H3529_002_1	4	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3529	002	2	1	02	01	H3529_002_2	4	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3529	002	3	1	02	01	H3529_002_3	4	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3529	002	4	1	02	01	H3529_002_4	4	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3533	033	0	1	01	01	H3533_033_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H3533	035	0	1	01	01	H3533_035_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H3533	036	1	1	01	01	H3533_036_1	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	12	6	bitewing x-rays 5/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	2	6	cone beam CT imaging 1/5 yrs, other diagnostic 1/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/lifetime, crown recement 1/tooth/2 yrs, crown 1/tooth/5 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	3	6	perio maint 2/yr, scaling/root planing 1 per quadrant/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1 every 8 years, denture adj 4/yr, rebase 1/5 yrs, reline, tissue cond 1/yr, repair 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	restoration implant 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	3	6	bridge recement 1 per quadrant/2 yrs, bridges-crown, bridges-pontic 1/tooth/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	1	6	other orthodontic 1/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2
H3533	036	2	1	01	01	H3533_036_2	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	5	6	comp oral exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	12	6	bitewing x-rays 5/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	2	6	cone beam CT imaging 1/5 yrs, other diagnostic 1/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/lifetime, crown recement 1/tooth/2 yrs, crown 1/tooth/5 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	3	6	perio maint 2/yr, scaling/root planing 1 per quadrant/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1 every 8 years, denture adj 4/yr, rebase 1/5 yrs, reline, tissue cond 1/yr, repair 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	restoration implant 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	3	6	bridge recement 1 per quadrant/2 yrs, bridges-crown, bridges-pontic 1/tooth/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2	2	2	1	6	other orthodontic 1/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2
H3533	037	0	1	01	01	H3533_037_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H3533	802	0	1	01	01	H3533_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3533	803	0	1	01	01	H3533_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3533	805	0	1	01	01	H3533_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3533	806	0	1	01	01	H3533_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3536	801	0	1	01	01	H3536_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3536	802	0	1	01	01	H3536_802_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3536	803	0	2	01	01	H3536_803_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3536	804	0	2	01	01	H3536_804_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3536	806	0	1	01	01	H3536_806_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3536	808	0	2	01	01	H3536_808_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3551	001	0	1	01	01	H3551_001_0	8	2				2				1	20.00	20.00	20.00	2		2	2	1		2800.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3551	003	0	1	02	01	H3551_003_0	7	2				1	20	20	20	2				2		2	2	1		2500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3551	004	0	1	01	01	H3551_004_0	8	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3551	005	0	1	01	01	H3551_005_0	11	2				2				1	20.00	20.00	20.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3557	801	0	1	04	01	H3557_801_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3557	802	0	1	04	01	H3557_802_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3557	803	0	1	04	01	H3557_803_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3561	007	0	1	01	01	H3561_007_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3561	009	0	1	01	01	H3561_009_0	5	2				1	20	20	20	2				2		1	2																																																																																																																		2								2					2		2	2	1	6	Per tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Per arch every 2 to 3 plan years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Per tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2																															2	2	1	3		2				1	0.00	0.00	0.00	1	2
H3561	010	1	1	01	01	H3561_010_1	5	2				1	20	20	20	2				2		1	2																																																																																																																		2								2					2		2	2	1	6	Per tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Per arch every 2 to 3 plan years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Per tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2																															2	2	1	3		2				1	0.00	0.00	0.00	1	2
H3561	010	2	1	01	01	H3561_010_2	5	2				1	20	20	20	2				2		1	2																																																																																																																		2								2					2		2	2	1	6	Per tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Per arch every 2 to 3 plan years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Per tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2																															2	2	1	3		2				1	0.00	0.00	0.00	1	2
H3563	001	0	1	20	08	H3563_001_0	1																																																																																																																																																																																																																																																																																																						
H3563	002	0	1	20	08	H3563_002_0	1																																																																																																																																																																																																																																																																																																						
H3597	001	0	1	02	01	H3597_001_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3597	011	0	1	02	01	H3597_011_0	3	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3597	012	0	1	02	01	H3597_012_0	3	2				1	30	30	30	2				2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3597	017	0	1	02	01	H3597_017_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3597	018	0	1	02	01	H3597_018_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3597	801	0	1	01	01	H3597_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3597	802	0	1	01	01	H3597_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3597	804	0	1	01	01	H3597_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3613	001	0	1	20	08	H3613_001_0	1																																																																																																																																																																																																																																																																																																						
H3613	002	0	1	20	08	H3613_002_0	1																																																																																																																																																																																																																																																																																																						
H3642	001	0	1	04	01	H3642_001_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H3642	801	0	1	04	01	H3642_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3642	802	0	1	04	01	H3642_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3642	803	0	2	04	01	H3642_803_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3642	804	0	2	04	01	H3642_804_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3642	805	0	1	04	01	H3642_805_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3642	806	0	1	04	01	H3642_806_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3642	807	0	1	04	01	H3642_807_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3642	808	0	1	04	01	H3642_808_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3642	809	0	1	04	01	H3642_809_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3642	810	0	1	04	01	H3642_810_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3642	811	0	1	04	01	H3642_811_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3642	812	0	1	04	01	H3642_812_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3655	041	0	1	02	01	H3655_041_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3655	045	1	1	02	01	H3655_045_1	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3655	045	2	1	02	01	H3655_045_2	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3655	045	3	1	02	01	H3655_045_3	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3655	045	4	1	02	01	H3655_045_4	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3655	801	0	1	01	01	H3655_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3655	803	0	1	01	01	H3655_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3655	805	0	2	01	01	H3655_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3655	806	0	2	01	01	H3655_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3655	808	0	1	01	01	H3655_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3655	810	0	2	01	01	H3655_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3655	811	0	1	01	01	H3655_811_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3660	028	0	1	02	01	H3660_028_0	10	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				3		50	70	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	1	50	50	50	2				2	2	3													2	2	4	2	1	6	Once per five years.	1	70	70	70	2				2	2																															4	2	1	6	Once per five years.	1	70	70	70	2				2	2	4	2	1	6	Once per tooth per lifetime.	3		50	70	2				2	2																4	1				2				2				2	2
H3660	029	0	1	02	01	H3660_029_0	10	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				3		50	70	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	1	50	50	50	2				2	2	3													2	2	4	2	1	6	Once per five years.	1	70	70	70	2				2	2																															4	2	1	6	Once per 5 year period.	1	70	70	70	2				2	2	4	2	1	6	Once per tooth per lifetime.	3		50	70	2				2	2																4	1				2				2				2	2
H3660	044	0	1	01	01	H3660_044_0	10	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				3		50	70	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	1	50	50	50	2				2	2	3													2	2	4	2	1	6	Once per five years.	1	70	70	70	2				2	2																															4	2	1	6	Once per five years.	1	70	70	70	2				2	2	4	2	1	6	Once per tooth per lifetime.	3		50	70	2				2	2																4	1				2				2				2	2
H3660	050	0	1	01	01	H3660_050_0	10	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				3		0	20	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2				2				2	2	3													2	2	4	2	1	6	Once per five years.	1	20	20	20	2				2	2																															4	2	1	6	Once per 5 year period.	1	20	20	20	2				2	2	4	2	1	6	Simple extractions and covered oral surgery services are payable once per tooth per lifetime.	3		0	20	2				2	2																4	1				2				2				2	2
H3660	057	0	1	01	01	H3660_057_0	12	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				3		50	70	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	1	50	50	50	2				2	2	3													2	2	4	2	1	6	Once per 5 years.	1	70	70	70	2				2	2																															4	2	1	6	Once per five years.	1	70	70	70	2				2	2	4	2	1	6	Once per tooth per lifetime.	3		50	70	2				2	2																4	1				2				2				2	2
H3660	058	0	1	01	01	H3660_058_0	8	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				3		0	50	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2				2				2	2	3													2	2	4	2	1	6	Once per five years.	1	50	50	50	2				2	2																															4	2	1	6	Once per 5 year period.	1	50	50	50	2				2	2	4	2	1	6	Simple extractions and covered oral surgery services are payable once per tooth per lifetime.	3		0	50	2				2	2																4	1				2				2				2	2
H3660	801	0	1	01	01	H3660_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3660	805	0	1	02	01	H3660_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3664	014	0	1	02	01	H3664_014_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Every 5 Years	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Every 5 Years	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2
H3664	017	0	1	02	01	H3664_017_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Every 5 Years	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Every 5 Years	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2
H3664	020	0	1	02	01	H3664_020_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		1300.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Every 5 Years	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2
H3664	021	0	1	02	01	H3664_021_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		850.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Every 5 Years	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Every 5 Years	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2
H3664	801	0	1	02	01	H3664_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3664	802	0	1	02	01	H3664_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3664	803	0	1	02	01	H3664_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3664	805	0	2	02	01	H3664_805_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3664	806	0	2	02	01	H3664_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3664	807	0	1	02	01	H3664_807_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3668	013	0	1	01	01	H3668_013_0	5	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	018	1	1	01	01	H3668_018_1	7	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3				2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	018	2	1	01	01	H3668_018_2	7	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3				2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	019	1	1	01	01	H3668_019_1	7	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3				2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	019	2	1	01	01	H3668_019_2	6	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3				2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	022	0	1	01	01	H3668_022_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	025	0	1	01	01	H3668_025_0	7	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	026	0	1	01	01	H3668_026_0	6	2				2				1	25.00	25.00	25.00	2		2	2	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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	2								2	2	1	1							2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	029	0	1	01	01	H3668_029_0	5	2				2				1	25.00	25.00	25.00	2		2	2	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	030	0	1	01	01	H3668_030_0	6	2				2				1	45.00	45.00	45.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing, or 1 per consecutive 36 months for comprehensive series.	2				2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	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				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3668	031	0	1	01	01	H3668_031_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing, or 1 per consecutive 36 months for comprehensive series.	2				2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	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				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3668	802	0	1	01	01	H3668_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3668	803	0	1	01	01	H3668_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3668	804	0	1	01	01	H3668_804_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3668	811	0	1	01	01	H3668_811_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3668	812	0	1	01	01	H3668_812_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3672	013	0	1	01	01	H3672_013_0	6	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		0	50	2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	3		0	50	2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	3		0	50	2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		0	50	2				2	2																															4	2	1	6	One crown per tooth every five calendar years	3		0	50	2				2	2	4	1				3		0	50	2				2	2																														
H3672	014	0	1	01	01	H3672_014_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. one panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		0	50	2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	3		0	50	2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	3		0	50	2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		0	50	2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	3		0	50	2				2	2	4	1				3		0	50	2				2	2																														
H3672	019	0	1	01	01	H3672_019_0	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	2	1	6	One per tooth every one - five years, depending on services.	2				2				2	2	2	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year	2				2				2	2	2	2	1	6	One - two treatments every one - three calendar years, depending on service.	2				2				2	2	2	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	2				2				2	2																															2	2	1	6	One crown per tooth every five calendar years.	2				2				2	2	2	1				2				2				2	2																														
H3672	020	0	1	01	01	H3672_020_0	6	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		0	50	2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	3		0	50	2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	3		0	50	2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		0	50	2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	3		0	50	2				2	2	4	1				3		0	50	2				2	2																														
H3672	021	0	1	01	01	H3672_021_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		0	50	2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	3		0	50	2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	3		0	50	2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		0	50	2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	3		0	50	2				2	2	4	1				3		0	50	2				2	2																														
H3672	805	0	1	01	01	H3672_805_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3706	001	0	1	01	01	H3706_001_0	5	2				2				1	40.00	40.00	40.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				2				2				2	2
H3706	009	0	1	01	01	H3706_009_0	4	2				2				1	35.00	35.00	35.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				2				2				2	2
H3706	023	0	1	01	01	H3706_023_0	5	2				2				1	30.00	30.00	30.00	2		1	1	1		1600.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				2				2				2	2
H3706	024	0	1	01	01	H3706_024_0	5	2				2				1	20.00	20.00	20.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				2				2				2	2
H3706	025	0	1	01	01	H3706_025_0	5	2				2				1	35.00	35.00	35.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				2				2				2	2
H3706	028	0	1	01	01	H3706_028_0	5	2				1	20	20	20	2				2		1	1	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	1				2				2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3706	029	0	1	01	01	H3706_029_0	5	2				1	20	20	20	2				2		1	1	1		3800.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	1				2				2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3706	803	0	1	01	01	H3706_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3708	001	0	1	01	01	H3708_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3727	002	1	1	01	01	H3727_002_1	5	2				2				2				2		2	2	1		2600.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3727	002	3	1	01	01	H3727_002_3	5	2				2				2				2		2	2	1		2600.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3727	006	0	1	01	01	H3727_006_0	7	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3727	007	0	1	01	01	H3727_007_0	5	2				2				2				2		2	2	1		2600.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3740	001	0	1	20	08	H3740_001_0	1																																																																																																																																																																																																																																																																																																						
H3740	002	0	1	20	08	H3740_002_0	1																																																																																																																																																																																																																																																																																																						
H3748	003	0	1	01	01	H3748_003_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3748	019	0	1	01	01	H3748_019_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3748	020	0	1	01	01	H3748_020_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3748	801	0	1	01	01	H3748_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3755	001	0	1	01	01	H3755_001_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1							2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2				2				1	2	2	2	1	6	Root canals are limited to 1 per lifetime per tooth. Therapeutic pulpotomoy and pulpal debridement are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months. Periodontal maintenance is limited to 2 every 12 months.	2				2				1	2	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months.  Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	2																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime	2				2				1	2																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays.  Teledentistry, synchronus or asynchronus limited to 1 per date of service.	2				2				2	2
H3755	002	0	1	01	01	H3755_002_0	7	2				2				1	5.00	5.00	5.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1							2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2				2				1	2	2	2	1	6	Root canals are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months. Periodontal maintenance is limited to 2 every 12 months.	2				2				1	2	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	2																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime	2				2				1	2																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays.  Teledentistry, synchronus or asynchronus limited to 1 per date of service.	2				2				2	2
H3755	004	0	1	01	01	H3755_004_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months. Limited oral evaluation problem focused is limited to 3 per 12 months.	2				2				2	2	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1							2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2				2				1	2	2	2	1	6	Root canals are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months.	2				2				1	2	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	2																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime.	2				2				1	2																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays.  Teledentistry, synchronus or asynchronus limited to 1 per date of service.	2				2				2	2
H3755	005	0	1	01	01	H3755_005_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months. Limited oral evaluation problem focused is limited to 3 per 12 months.	2				2				2	2	2	2	1	6	Bitewings (1-4 films) are  limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1							2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2				2				1	2	2	2	1	6	Root canals are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months.	2				2				1	2	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	2																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime.	2				2				1	2																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays.  Teledentistry, synchronus or asynchronus limited to 1 per date of service.	2				2				2	2
H3755	006	0	1	01	01	H3755_006_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1							2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth per surface.	2				2				1	2	2	2	1	6	Root canals are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months.	2				2				1	2	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	2																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime.	2				2				1	2																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays.	2				2				2	2
H3755	007	0	1	01	01	H3755_007_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months. Limited oral evaluation problem focused is limited to 3 per 12 months.	2				2				2	2	2	2	1	6	Bitewings (1-4 films) limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1							2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2				2				1	2	2	2	1	6	Root canals are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months.	2				2				1	2	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	2																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime.	2				2				1	2																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays	2				2				2	2
H3755	801	0	1	01	01	H3755_801_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3767	001	0	1	01	01	H3767_001_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H3767	002	0	1	01	01	H3767_002_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H3794	002	0	1	02	01	H3794_002_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3794	004	0	1	02	01	H3794_004_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3794	010	0	1	02	01	H3794_010_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3794	011	1	1	02	01	H3794_011_1	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3794	011	2	1	02	01	H3794_011_2	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3794	011	3	1	02	01	H3794_011_3	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3800	001	0	1	01	01	H3800_001_0	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3805	015	0	1	02	01	H3805_015_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3805	017	0	1	02	01	H3805_017_0	5	2				1	20	20	20	2				2		1	2																																																																																																																		2								2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H3805	032	0	1	02	01	H3805_032_0	3	2				1	20	20	20	2				2		1	2																																																																																																																		2								2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H3805	033	0	1	02	01	H3805_033_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3805	035	0	1	02	01	H3805_035_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3805	040	0	1	02	01	H3805_040_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3805	041	0	1	02	01	H3805_041_0	4	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3805	044	0	1	02	01	H3805_044_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3805	045	0	1	02	01	H3805_045_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H3805	048	0	1	02	01	H3805_048_0	5	2				1	20	20	20	2				2		1	2																																																																																																																		2								2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H3805	049	0	1	02	01	H3805_049_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3805	050	0	1	02	01	H3805_050_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3805	051	0	1	02	01	H3805_051_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3805	801	0	1	01	01	H3805_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3805	803	0	1	01	01	H3805_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3805	804	0	1	01	01	H3805_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3805	805	0	1	01	01	H3805_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3805	806	0	1	01	01	H3805_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3805	807	0	1	01	01	H3805_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3809	001	0	1	20	08	H3809_001_0	1																																																																																																																																																																																																																																																																																																						
H3809	002	0	1	20	08	H3809_002_0	1																																																																																																																																																																																																																																																																																																						
H3810	023	0	1	01	01	H3810_023_0	8	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3811	003	0	1	01	01	H3811_003_0	5	2				1	20	20	20	2				2		1	2	1		500.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3814	007	0	1	01	01	H3814_007_0	9	2				1	20	20	20	2				2		2	2	1		300.00	4		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3814	030	0	1	01	01	H3814_030_0	8	2				1	20	20	20	2				2		2	2	1		500.00	4		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3815	001	0	1	01	01	H3815_001_0	12	2				2				2				2		1	2	2							2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																2								2					2		4	1				2				3		20.00	400.00	1	2	4	1				2				3		25.00	350.00	1	2	4	1				2				3		15.00	550.00	1	2	4	1				2				3		20.00	570.00	1	2																															4	1				2				3		40.00	400.00	1	2	4	1				2				3		25.00	250.00	1	2																														
H3815	008	0	1	01	01	H3815_008_0	13	2				2				2				2		1	2	2							2				2					2					2		4	1				2				1	10.00	10.00	10.00	1	2	4	1				2				1	30.00	30.00	30.00	1	2																4	1				2				1	20.00	20.00	20.00	1	2	4	1				2				1	10.00	10.00	10.00	1	2																2								2					2		4	1				2				3		20.00	400.00	1	2	4	1				2				3		25.00	350.00	1	2	4	1				2				3		15.00	550.00	1	2	4	1				2				3		20.00	570.00	1	2																															4	1				2				3		40.00	400.00	1	2	4	1				2				3		25.00	250.00	1	2																														
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H3815	053	0	1	01	01	H3815_053_0	10	2				2				2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3815	054	0	1	01	01	H3815_054_0	10	2				2				2				2		1	2	2							2				2					2					2		4	2	1	4		2				2				1	1	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																2								2					2		4	1				2				3		20.00	400.00	1	2	4	1				2				3		25.00	350.00	1	2	4	1				2				3		15.00	550.00	1	2	4	1				2				3		20.00	570.00	1	2																															4	1				2				3		40.00	400.00	1	2	4	1				2				3		25.00	250.00	1	2																														
H3815	055	0	1	01	01	H3815_055_0	11	2				2				2				2		1	2	2							2				2					2					2		4	2	1	4		2				2				1	1	4	2	1	1		2				2				1	1																4	2	1	4		2				2				1	1	4	2	1	4		2				2				1	1																																																																																																																																																																																				
H3815	056	0	1	01	01	H3815_056_0	10	2				2				2				2		1	2	2							2				2					2					2		4	2	1	4		2				2				1	1	4	2	1	1		2				2				1	1																4	2	1	4		2				2				1	1	4	2	1	4		2				2				1	1																																																																																																																																																																																				
H3815	057	0	1	01	01	H3815_057_0	10	2				2				2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3815	059	0	1	01	01	H3815_059_0	11	2				2				2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	350.00	1	2	2	1				2				3		15.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		25.00	250.00	1	2																														
H3815	060	0	1	01	01	H3815_060_0	11	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	2		500.00	5		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3815	061	0	1	01	01	H3815_061_0	10	2				2				2				2		1	2	1		1000.00	3		2		2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																1	1							2					2		4	1				2				2				1	2	4	1				2				2				1	2	4	1				2				2				1	2	4	1				2				2				1	2																															4	1				2				2				1	2	4	1				2				2				1	2																														
H3815	801	0	1	01	01	H3815_801_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H3815	802	0	1	01	01	H3815_802_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H3815	803	0	1	01	01	H3815_803_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H3815	804	0	1	01	01	H3815_804_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H3817	008	1	1	04	01	H3817_008_1	7	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1250.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H3817	008	2	1	04	01	H3817_008_2	7	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1250.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H3817	008	4	1	04	01	H3817_008_4	8	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1250.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H3817	009	1	1	04	01	H3817_009_1	7	2				2				1	30.00	30.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H3817	009	2	1	04	01	H3817_009_2	7	2				2				1	30.00	30.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H3817	010	0	1	04	01	H3817_010_0	5	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H3817	011	1	1	04	01	H3817_011_1	10	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1000.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H3817	011	2	1	04	01	H3817_011_2	10	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1000.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H3817	011	3	1	04	01	H3817_011_3	10	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1000.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H3817	801	0	1	04	01	H3817_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3817	802	0	1	04	01	H3817_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3822	001	0	1	02	01	H3822_001_0	7	2				2				1	20.00	20.00	20.00	2		2	2	1		750.00	3		2		2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Complete series x-rays and panoramic x-rays are limited to once every five years. Bitewing x-rays covered every year. Six periapical x-rays covered every year.	2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2																															1	1							2					2		4	1				3		0	50	2				2	2	3													2	2	4	1				2				2				2	2	3													2	2																4	1				2				2				2	2	3													2	2	4	1				1	50	50	50	2				2	2																4	1				3		0	50	2				2	2
H3822	002	0	1	02	01	H3822_002_0	7	2				2				1	35.00	35.00	35.00	2		2	2	1		750.00	3		2		2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Complete series x-rays and panoramic x-rays are limited to once every five years. Bitewing x-rays covered every year. Six periapical x-rays covered every year.	2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2																															1	1							2					2		4	1				3		0	50	2				2	2	3													2	2	4	1				2				2				2	2	3													2	2																4	1				2				2				2	2	3													2	2	4	1				1	50	50	50	2				2	2																4	1				3		0	50	2				2	2
H3822	017	0	1	02	01	H3822_017_0	8	2				1	20	20	20	2				2		2	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays are limited to once every five years. Bitewing x-rays covered every year. Six periapical x-rays covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2																															1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3822	018	0	1	02	01	H3822_018_0	7	2				1	20	20	20	2				2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays are limited to once every five years. Bitewing x-rays covered every year. Six periapical x-rays covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2																															1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3822	019	0	1	02	01	H3822_019_0	7	2				2				1	25.00	25.00	25.00	2		2	2	1		750.00	3		2		2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Complete series x-rays and panoramic x-rays are limited to once every five years. Bitewing x-rays covered every year. Six periapical x-rays covered every year.	2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2																															1	1							2					2		4	1				3		0	50	2				2	2	3													2	2	4	1				2				2				2	2	3													2	2																4	1				2				2				2	2	3													2	2	4	1				1	50	50	50	2				2	2																4	1				3		0	50	2				2	2
H3822	801	0	1	01	01	H3822_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3822	802	0	1	01	01	H3822_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3822	805	0	1	01	01	H3822_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3822	806	0	1	01	01	H3822_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3822	809	0	1	01	01	H3822_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3822	810	0	1	01	01	H3822_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3822	813	0	1	01	01	H3822_813_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3822	814	0	1	01	01	H3822_814_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3822	815	0	1	01	01	H3822_815_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3822	816	0	1	01	01	H3822_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3822	818	0	1	01	01	H3822_818_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3832	007	0	1	04	01	H3832_007_0	8	2				2				1	55.00	55.00	55.00	2		2	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																													2	2	4	3		2				1	0.00	0.00	0.00	2	2																														
H3832	009	0	1	04	01	H3832_009_0	8	2				2				1	55.00	55.00	55.00	2		2	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																													2	2	4	3		2				1	0.00	0.00	0.00	2	2																														
H3832	014	0	1	04	01	H3832_014_0	8	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																													2	2	4	3		2				1	0.00	0.00	0.00	2	2																														
H3832	015	0	1	04	01	H3832_015_0	9	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																													2	2	4	3		2				1	0.00	0.00	0.00	2	2																														
H3832	801	0	1	04	01	H3832_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3832	802	0	1	04	01	H3832_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3832	805	0	1	04	01	H3832_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3832	807	0	1	04	01	H3832_807_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3864	002	0	1	02	01	H3864_002_0	7	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	006	0	1	02	01	H3864_006_0	9	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	036	0	1	02	01	H3864_036_0	11	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	043	0	1	01	01	H3864_043_0	10	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3864	046	0	1	02	01	H3864_046_0	9	2				2				1	55.00	55.00	55.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																																																																																																																																																					
H3864	049	0	1	02	01	H3864_049_0	9	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	050	0	1	02	01	H3864_050_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	801	0	1	01	01	H3864_801_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3864	803	0	1	01	01	H3864_803_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3864	805	0	1	02	01	H3864_805_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3864	806	0	1	02	01	H3864_806_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3868	001	0	1	02	01	H3868_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3868	003	1	1	02	01	H3868_003_1	4	2				1	20	20	20	2				2		1	2	1		1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3868	003	2	1	02	01	H3868_003_2	4	2				1	20	20	20	2				2		1	2	1		1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3868	003	3	1	02	01	H3868_003_3	4	2				1	20	20	20	2				2		1	2	1		1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3868	004	1	1	02	01	H3868_004_1	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3868	004	2	1	02	01	H3868_004_2	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3868	005	0	1	02	01	H3868_005_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H3868	007	0	1	02	01	H3868_007_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H3879	001	0	1	02	01	H3879_001_0	10	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																															2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H3879	002	0	1	02	01	H3879_002_0	11	2				1	20	20	20	2				2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H3890	001	0	1	04	01	H3890_001_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodic oral exams, Extensive oral exam  problem focused, Re-Evaluation  limited problem focused  two per calendar yearLimited Oral Exam  3 per calendar YearComprehensive Oral Exam or Comprehensive Periodontal Exam  One per 3 years per provider or location	2				2				2	2	2	2	1	6	Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 yearsIntraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																				
H3890	002	0	1	04	01	H3890_002_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodic oral exams, Extensive oral exam  problem focused, Re-Evaluation  limited problem focused  two per calendar yearLimited Oral Exam  3 per calendar YearComprehensive Oral Exam or Comprehensive Periodontal Exam  One per 3 years per provider or location	2				2				2	2	2	2	1	6	Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 yearsIntraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																				
H3890	006	0	1	04	01	H3890_006_0	10	2				2				2				2		2	2	1	2	1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3890	801	0	1	04	01	H3890_801_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3907	002	0	1	01	01	H3907_002_0	9	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		3000.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	006	0	1	01	01	H3907_006_0	8	2				2				1	10.00	10.00	10.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every year. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5500.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	037	0	1	01	01	H3907_037_0	8	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		3000.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	1	1	01	01	H3907_057_1	8	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		3000.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	2	1	01	01	H3907_057_2	7	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2250.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	3	1	01	01	H3907_057_3	8	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2700.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	4	1	01	01	H3907_057_4	8	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		3000.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	8	1	01	01	H3907_057_8	7	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	058	1	1	01	01	H3907_058_1	7	2				2				1	25.00	25.00	25.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	058	2	1	01	01	H3907_058_2	7	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		3000.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	058	3	1	01	01	H3907_058_3	7	2				2				1	25.00	25.00	25.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		4000.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	059	1	1	01	01	H3907_059_1	9	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	059	2	1	01	01	H3907_059_2	8	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	059	3	1	01	01	H3907_059_3	9	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2100.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	061	0	1	01	01	H3907_061_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	062	0	1	01	01	H3907_062_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		3000.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	063	0	1	01	01	H3907_063_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		4500.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	064	0	1	01	01	H3907_064_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2500.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	801	0	1	01	01	H3907_801_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3907	802	0	1	01	01	H3907_802_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3907	803	0	1	01	01	H3907_803_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3907	804	0	1	01	01	H3907_804_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3909	001	0	1	04	01	H3909_001_0	9	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in the note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1500.00	3		2		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																															2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3909	007	0	1	04	01	H3909_007_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in the note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1500.00	3		2		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																															2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3909	009	0	1	04	01	H3909_009_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in the note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1500.00	3		2		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																															2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3909	020	0	1	04	01	H3909_020_0	7	2				2				1	60.00	60.00	60.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H3909	801	0	1	04	01	H3909_801_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3909	802	0	1	04	01	H3909_802_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3909	803	0	1	04	01	H3909_803_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3916	001	0	1	04	01	H3916_001_0	9	2				2				1	25.00	25.00	25.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3916	002	0	1	04	01	H3916_002_0	8	2				2				1	25.00	25.00	25.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3916	005	0	1	04	01	H3916_005_0	8	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3916	012	0	1	04	01	H3916_012_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3916	015	0	1	04	01	H3916_015_0	10	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3916	018	0	1	04	01	H3916_018_0	8	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3916	022	0	1	04	01	H3916_022_0	8	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3916	024	0	1	04	01	H3916_024_0	8	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3916	032	0	1	04	01	H3916_032_0	8	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3916	033	0	1	04	01	H3916_033_0	8	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3916	035	1	1	04	01	H3916_035_1	9	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		1	10	10	10	2				2	2
H3916	035	2	1	04	01	H3916_035_2	11	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		1	10	10	10	2				2	2
H3916	035	5	1	04	01	H3916_035_5	9	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H3916	037	2	1	04	01	H3916_037_2	8	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	30	30	30	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	30	30	30	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	30	30	30	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	30	30	30	2				2	2																2	2	2	3		1	30	30	30	2				2	2
H3916	037	4	1	04	01	H3916_037_4	10	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	30	30	30	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	30	30	30	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	30	30	30	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	30	30	30	2				2	2																2	2	2	3		1	30	30	30	2				2	2
H3916	037	5	1	04	01	H3916_037_5	8	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	30	30	30	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	30	30	30	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	30	30	30	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	30	30	30	2				2	2																2	2	2	3		1	30	30	30	2				2	2
H3916	037	6	1	04	01	H3916_037_6	10	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	30	30	30	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	30	30	30	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	30	30	30	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	30	30	30	2				2	2																2	2	2	3		1	30	30	30	2				2	2
H3916	037	7	1	04	01	H3916_037_7	10	2				2				1	45.00	45.00	45.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	037	8	1	04	01	H3916_037_8	10	2				2				1	45.00	45.00	45.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	039	0	1	04	01	H3916_039_0	11	2				2				1	45.00	45.00	45.00	2		2	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	35	35	35	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	35	35	35	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	35	35	35	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	35	35	35	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	35	35	35	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	35	35	35	2				2	2																2	2	2	3		1	35	35	35	2				2	2
H3916	041	1	1	04	01	H3916_041_1	12	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	30	30	30	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	30	30	30	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	30	30	30	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	30	30	30	2				2	2																2	2	2	3		1	30	30	30	2				2	2
H3916	041	2	1	04	01	H3916_041_2	11	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	30	30	30	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	30	30	30	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	30	30	30	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	30	30	30	2				2	2																2	2	2	3		1	30	30	30	2				2	2
H3916	041	3	1	04	01	H3916_041_3	11	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	30	30	30	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	30	30	30	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	30	30	30	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	30	30	30	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	30	30	30	2				2	2																2	2	2	3		1	30	30	30	2				2	2
H3916	043	0	1	04	01	H3916_043_0	6	2				2				1	10.00	10.00	10.00	2		2	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3916	056	0	1	04	01	H3916_056_0	6	2				2				1	10.00	10.00	10.00	2		2	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3916	057	0	1	04	01	H3916_057_0	8	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	058	0	1	04	01	H3916_058_0	11	2				2				1	65.00	65.00	65.00	2		2	2	1	2	750.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	060	1	1	04	01	H3916_060_1	9	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H3916	060	2	1	04	01	H3916_060_2	9	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H3916	060	3	1	04	01	H3916_060_3	9	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H3916	060	4	1	04	01	H3916_060_4	9	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H3916	060	5	1	04	01	H3916_060_5	9	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		1	25	25	25	2				2	2
H3916	060	6	1	04	01	H3916_060_6	9	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	061	1	1	04	01	H3916_061_1	10	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		1	25	25	25	2				2	2
H3916	061	2	1	04	01	H3916_061_2	10	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	062	0	1	04	01	H3916_062_0	10	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	063	0	1	04	01	H3916_063_0	9	2				2				1	65.00	65.00	65.00	2		2	2	1	2	750.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	064	0	1	04	01	H3916_064_0	9	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	065	0	1	04	01	H3916_065_0	8	2				2				1	70.00	70.00	70.00	2		2	2	1	2	750.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	067	0	1	04	01	H3916_067_0	6	2				2				1	10.00	10.00	10.00	2		2	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3916	069	1	1	04	01	H3916_069_1	9	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	069	2	1	04	01	H3916_069_2	11	2				2				1	60.00	60.00	60.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3916	801	0	1	04	01	H3916_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3916	802	0	1	04	01	H3916_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3916	804	0	1	04	01	H3916_804_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3916	805	0	1	04	01	H3916_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3916	806	0	1	04	01	H3916_806_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3916	807	0	1	04	01	H3916_807_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3916	808	0	1	04	01	H3916_808_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3916	809	0	1	04	01	H3916_809_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3916	810	0	1	04	01	H3916_810_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3917	001	0	1	20	08	H3917_001_0	1																																																																																																																																																																																																																																																																																																						
H3917	002	0	1	20	08	H3917_002_0	1																																																																																																																																																																																																																																																																																																						
H3918	001	0	1	20	08	H3918_001_0	1																																																																																																																																																																																																																																																																																																						
H3918	002	0	1	20	08	H3918_002_0	1																																																																																																																																																																																																																																																																																																						
H3919	001	0	1	20	08	H3919_001_0	1																																																																																																																																																																																																																																																																																																						
H3919	002	0	1	20	08	H3919_002_0	1																																																																																																																																																																																																																																																																																																						
H3923	013	0	1	04	01	H3923_013_0	7	2				2				1	25.00	25.00	25.00	2		2	2	1	2	2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	017	0	1	04	01	H3923_017_0	6	2				2				1	25.00	25.00	25.00	2		2	2	1	2	2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement.	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	044	1	1	04	01	H3923_044_1	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	044	2	1	04	01	H3923_044_2	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	044	3	1	04	01	H3923_044_3	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	044	4	1	04	01	H3923_044_4	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	045	1	1	04	01	H3923_045_1	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	045	2	1	04	01	H3923_045_2	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	045	3	1	04	01	H3923_045_3	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	045	4	1	04	01	H3923_045_4	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	045	5	1	04	01	H3923_045_5	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	046	1	1	04	01	H3923_046_1	5	2				2				1	15.00	15.00	15.00	2		2	2	1	2	2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	046	2	1	04	01	H3923_046_2	5	2				2				1	20.00	20.00	20.00	2		2	2	1	2	2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	046	3	1	04	01	H3923_046_3	5	2				2				1	15.00	15.00	15.00	2		2	2	1	2	2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	046	4	1	04	01	H3923_046_4	5	2				2				1	25.00	25.00	25.00	2		2	2	1	2	2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	047	1	1	04	01	H3923_047_1	5	2				2				1	15.00	15.00	15.00	2		2	2	1	2	3500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	047	2	1	04	01	H3923_047_2	5	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline & rebase-1 per 24 months, only after 24 months from date of placement.	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	047	3	1	04	01	H3923_047_3	5	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement.	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline & rebase-1 per 24 months, only after 24 months from date of placement.	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	047	4	1	04	01	H3923_047_4	5	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement.	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	049	1	1	04	01	H3923_049_1	4	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	049	2	1	04	01	H3923_049_2	4	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	049	3	1	04	01	H3923_049_3	4	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	049	4	1	04	01	H3923_049_4	4	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	049	5	1	04	01	H3923_049_5	4	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	801	0	1	04	01	H3923_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3923	802	0	1	04	01	H3923_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3923	817	0	1	04	01	H3923_817_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3923	818	0	1	04	01	H3923_818_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3923	819	0	1	04	01	H3923_819_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3923	820	0	1	04	01	H3923_820_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3923	832	0	1	04	01	H3923_832_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3924	059	21	1	04	01	H3924_059_21	5	2				2				1	25.00	25.00	25.00	2		1	2																																																																																																																																																																																																																																																																																						
H3924	059	22	1	04	01	H3924_059_22	5	2				2				1	25.00	25.00	25.00	2		1	2																																																																																																																																																																																																																																																																																						
H3924	065	0	1	04	01	H3924_065_0	5	2				2				1	40.00	40.00	40.00	2		1	2																																																																																																																																																																																																																																																																																						
H3924	067	0	1	04	01	H3924_067_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3924	804	0	1	04	01	H3924_804_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3924	805	0	1	04	01	H3924_805_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3925	001	0	1	20	08	H3925_001_0	1																																																																																																																																																																																																																																																																																																						
H3925	002	0	1	20	08	H3925_002_0	1																																																																																																																																																																																																																																																																																																						
H3928	001	0	1	01	01	H3928_001_0	5	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3928	801	0	1	01	01	H3928_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3928	803	0	1	01	01	H3928_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3928	805	0	1	01	01	H3928_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3931	094	0	1	01	01	H3931_094_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3931	095	0	1	02	01	H3931_095_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	099	0	1	02	01	H3931_099_0	3	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	100	0	1	02	01	H3931_100_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	101	0	1	02	01	H3931_101_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	143	0	1	01	01	H3931_143_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3931	151	0	1	01	01	H3931_151_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3931	157	0	1	01	01	H3931_157_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3931	158	0	1	02	01	H3931_158_0	3	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	160	0	1	01	01	H3931_160_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3931	162	0	1	01	01	H3931_162_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3931	175	0	1	01	01	H3931_175_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3931	190	0	1	02	01	H3931_190_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3931	191	0	1	01	01	H3931_191_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3931	196	0	1	01	01	H3931_196_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3931	197	0	1	01	01	H3931_197_0	3	2				2				1	70.00	70.00	70.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3931	198	0	1	01	01	H3931_198_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3931	801	0	1	01	01	H3931_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3931	804	0	1	01	01	H3931_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3931	808	0	1	01	01	H3931_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3933	001	0	1	20	08	H3933_001_0	1																																																																																																																																																																																																																																																																																																						
H3933	002	0	1	20	08	H3933_002_0	1																																																																																																																																																																																																																																																																																																						
H3942	001	0	1	20	08	H3942_001_0	1																																																																																																																																																																																																																																																																																																						
H3942	002	0	1	20	08	H3942_002_0	1																																																																																																																																																																																																																																																																																																						
H3949	009	0	1	01	01	H3949_009_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3949	024	0	1	01	01	H3949_024_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	030	0	1	01	01	H3949_030_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		2250.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3949	031	0	1	01	01	H3949_031_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	035	0	1	01	01	H3949_035_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	047	0	1	01	01	H3949_047_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	048	0	1	01	01	H3949_048_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	052	0	1	01	01	H3949_052_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		1100.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3949	053	0	1	01	01	H3949_053_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3949	054	0	1	01	01	H3949_054_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		300.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3949	804	0	1	01	01	H3949_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H3952	008	0	1	01	01	H3952_008_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3952	020	0	1	01	01	H3952_020_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3952	045	0	1	01	01	H3952_045_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H3952	048	0	1	01	01	H3952_048_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1500.00	3		2		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life.	1	40	40	40	2				2	2																															2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	049	0	1	01	01	H3952_049_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1500.00	3		2		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life.	1	40	40	40	2				2	2																															2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	050	0	1	01	01	H3952_050_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1500.00	3		2		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life.	1	40	40	40	2				2	2																															2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	051	0	1	01	01	H3952_051_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1500.00	3		2		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life.	1	40	40	40	2				2	2																															2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	053	0	1	02	01	H3952_053_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H3952	054	0	1	02	01	H3952_054_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H3952	055	0	1	01	01	H3952_055_0	8	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in the note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1200.00	3		2		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																															2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	059	0	1	01	01	H3952_059_0	6	2				2				1	55.00	55.00	55.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		2000.00	3		2		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																															2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	060	0	1	02	01	H3952_060_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1500.00	3		2		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																															2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	062	0	1	01	01	H3952_062_0	7	2				2				1	46.00	46.00	46.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in the note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H3952	802	0	1	01	01	H3952_802_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3952	804	0	1	01	01	H3952_804_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3952	805	0	1	01	01	H3952_805_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3954	097	0	1	01	01	H3954_097_0	5	2				1	20	20	20	2				2		1	2	1		4500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	157	21	1	01	01	H3954_157_21	5	2				2				1	20.00	20.00	20.00	2		1	2	1		1250.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	157	22	1	01	01	H3954_157_22	5	2				2				1	20.00	20.00	20.00	2		1	2	1		1250.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	157	23	1	01	01	H3954_157_23	5	2				2				1	20.00	20.00	20.00	2		1	2	1		1250.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	158	13	1	01	01	H3954_158_13	5	2				2				1	35.00	35.00	35.00	2		1	2	1		750.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	158	14	1	01	01	H3954_158_14	5	2				2				1	35.00	35.00	35.00	2		1	2	1		750.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	160	0	1	01	01	H3954_160_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		750.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	161	0	1	01	01	H3954_161_0	5	2				2				1	35.00	35.00	35.00	2		1	2																																																																																																																																																																																																																																																																																						
H3954	162	0	1	01	01	H3954_162_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	163	0	1	01	01	H3954_163_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	801	0	1	01	01	H3954_801_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3954	802	0	1	01	01	H3954_802_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3954	805	0	1	01	01	H3954_805_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3954	806	0	1	01	01	H3954_806_0	3	2				2				2				2		1	2	2							2				2					2					2																	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3957	031	0	1	02	01	H3957_031_0	9	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3957	042	1	1	01	01	H3957_042_1	12	2				2				1	30.00	30.00	30.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		1	10	10	10	2				2	2
H3957	042	2	1	01	01	H3957_042_2	12	2				2				1	30.00	30.00	30.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		1	10	10	10	2				2	2
H3957	042	4	1	01	01	H3957_042_4	12	2				2				1	35.00	35.00	35.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		1	10	10	10	2				2	2
H3957	042	5	1	01	01	H3957_042_5	12	2				2				1	35.00	35.00	35.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H3957	042	7	1	01	01	H3957_042_7	12	2				2				1	30.00	30.00	30.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		1	10	10	10	2				2	2
H3957	043	1	1	02	01	H3957_043_1	6	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3957	043	2	1	02	01	H3957_043_2	6	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3957	044	1	1	02	01	H3957_044_1	8	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3957	044	4	1	02	01	H3957_044_4	8	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3957	045	1	1	02	01	H3957_045_1	8	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3957	045	2	1	02	01	H3957_045_2	8	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3957	046	1	1	02	01	H3957_046_1	8	2				2				1	25.00	25.00	25.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3957	046	2	1	02	01	H3957_046_2	8	2				2				1	25.00	25.00	25.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H3957	047	1	1	01	01	H3957_047_1	9	2				2				1	25.00	25.00	25.00	2		2	2	1		2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H3957	047	2	1	01	01	H3957_047_2	8	2				2				1	25.00	25.00	25.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H3957	047	3	1	01	01	H3957_047_3	9	2				2				1	35.00	35.00	35.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H3957	047	4	1	01	01	H3957_047_4	10	2				2				1	40.00	40.00	40.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3957	047	5	1	01	01	H3957_047_5	10	2				2				1	40.00	40.00	40.00	2		2	2	1		1250.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3957	048	0	1	01	01	H3957_048_0	11	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	1	1	01	01	H3957_049_1	8	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	2	1	01	01	H3957_049_2	8	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	3	1	01	01	H3957_049_3	8	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	4	1	01	01	H3957_049_4	8	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	5	1	01	01	H3957_049_5	8	2				2				1	30.00	30.00	30.00	2		2	2	1		2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	6	1	01	01	H3957_049_6	8	2				2				1	30.00	30.00	30.00	2		2	2	1		2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	7	1	01	01	H3957_049_7	8	2				2				1	35.00	35.00	35.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		1	10	10	10	2				2	2
H3957	050	1	1	01	01	H3957_050_1	8	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	050	2	1	01	01	H3957_050_2	8	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	050	3	1	01	01	H3957_050_3	8	2				2				1	25.00	25.00	25.00	2		2	2	1		2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	050	4	1	01	01	H3957_050_4	8	2				2				1	25.00	25.00	25.00	2		2	2	1		2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		1	10	10	10	2				2	2
H3957	050	5	1	01	01	H3957_050_5	8	2				2				1	30.00	30.00	30.00	2		2	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		1	10	10	10	2				2	2
H3957	051	0	1	01	01	H3957_051_0	7	2				2				1	55.00	55.00	55.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		1	25	25	25	2				2	2
H3957	805	0	1	01	01	H3957_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3957	806	0	1	01	01	H3957_806_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3957	808	0	1	01	01	H3957_808_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3957	810	0	1	01	01	H3957_810_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3957	811	0	1	01	01	H3957_811_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3957	812	0	1	01	01	H3957_812_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3957	813	0	1	02	01	H3957_813_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3957	814	0	1	02	01	H3957_814_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3957	815	0	1	02	01	H3957_815_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3957	816	0	1	01	01	H3957_816_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3957	817	0	1	02	01	H3957_817_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3957	818	0	1	01	01	H3957_818_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3959	001	0	1	02	01	H3959_001_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	002	0	1	02	01	H3959_002_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	010	0	1	02	01	H3959_010_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	011	0	1	02	01	H3959_011_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	032	0	1	02	01	H3959_032_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	033	0	1	02	01	H3959_033_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	035	0	1	01	01	H3959_035_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	036	0	1	01	01	H3959_036_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	037	0	1	02	01	H3959_037_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	039	0	1	02	01	H3959_039_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	041	0	1	02	01	H3959_041_0	3	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	052	0	1	02	01	H3959_052_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3959	053	0	1	02	01	H3959_053_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	055	0	1	01	01	H3959_055_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	056	0	1	01	01	H3959_056_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	066	0	1	01	01	H3959_066_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	074	0	1	01	01	H3959_074_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	075	0	1	01	01	H3959_075_0	3	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	076	0	1	01	01	H3959_076_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	083	0	1	01	01	H3959_083_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	084	0	1	01	01	H3959_084_0	3	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	085	0	1	01	01	H3959_085_0	3	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	088	0	1	01	01	H3959_088_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	089	0	1	01	01	H3959_089_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	090	0	1	01	01	H3959_090_0	3	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	091	0	1	01	01	H3959_091_0	3	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	092	0	1	01	01	H3959_092_0	3	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	093	0	1	02	01	H3959_093_0	3	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3959	094	0	1	02	01	H3959_094_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3959	097	0	1	01	01	H3959_097_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	098	0	1	01	01	H3959_098_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	101	0	1	02	01	H3959_101_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3959	102	0	1	01	01	H3959_102_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3959	804	0	1	01	01	H3959_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3962	001	0	1	01	01	H3962_001_0	5	2				2				1	15.00	15.00	15.00	2		2	2	1		3000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3962	022	1	1	01	01	H3962_022_1	6	2				2				1	25.00	25.00	25.00	2		2	2	1		2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3962	022	2	1	01	01	H3962_022_2	6	2				2				1	30.00	30.00	30.00	2		2	2	1		2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3962	022	3	1	01	01	H3962_022_3	6	2				2				1	30.00	30.00	30.00	2		2	2	1		2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3962	022	4	1	01	01	H3962_022_4	6	2				2				1	30.00	30.00	30.00	2		2	2	1		2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3962	022	5	1	01	01	H3962_022_5	6	2				2				1	20.00	20.00	20.00	2		2	2	1		2000.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3962	023	1	1	01	01	H3962_023_1	7	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3962	023	2	1	01	01	H3962_023_2	7	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3962	023	3	1	01	01	H3962_023_3	7	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3962	023	4	1	01	01	H3962_023_4	7	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3962	023	5	1	01	01	H3962_023_5	7	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3				2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1							2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3962	801	0	1	01	01	H3962_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3962	802	0	1	01	01	H3962_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3962	813	0	1	01	01	H3962_813_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3962	817	0	1	01	01	H3962_817_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3962	828	0	1	01	01	H3962_828_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H3975	001	0	1	04	01	H3975_001_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	Once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	Every 6 months to 2 years	1	20	20	20	2				1	2	2	2	1	6	Every year to 5 years	1	20	20	20	2				1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	1	20	20	20	2				1	2																2	2	1	6	Every date of service to every 5 years	1	20	20	20	2				1	2
H3975	004	0	1	04	01	H3975_004_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H3991	001	0	1	20	08	H3991_001_0	1																																																																																																																																																																																																																																																																																																						
H3991	002	0	1	20	08	H3991_002_0	1																																																																																																																																																																																																																																																																																																						
H4003	009	0	1	01	01	H4003_009_0	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		2500.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	017	0	1	01	01	H4003_017_0	5	2				2				2				2		1	2																																																																																																																		1	2		3500.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	034	0	1	02	01	H4003_034_0	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		2500.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	055	0	1	02	01	H4003_055_0	4	2				3		0	20	2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																																																																																																																																																																					
H4003	058	0	1	01	01	H4003_058_0	4	2				2				2				2		1	2																																																																																																																		1	2		1500.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	059	1	1	02	01	H4003_059_1	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		2000.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	059	2	1	02	01	H4003_059_2	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		2000.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	059	3	1	02	01	H4003_059_3	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		2000.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	806	0	1	02	01	H4003_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	807	0	1	02	01	H4003_807_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	820	0	1	02	01	H4003_820_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	821	0	1	02	01	H4003_821_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	822	0	1	02	01	H4003_822_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	823	0	1	02	01	H4003_823_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	824	0	1	02	01	H4003_824_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	825	0	1	02	01	H4003_825_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	826	0	1	02	01	H4003_826_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	827	0	1	02	01	H4003_827_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	828	0	1	02	01	H4003_828_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	829	0	1	02	01	H4003_829_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	830	0	1	02	01	H4003_830_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	831	0	1	02	01	H4003_831_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	832	0	1	02	01	H4003_832_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4003	833	0	1	02	01	H4003_833_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	048	0	1	01	01	H4004_048_0	4	2				2				2				2		1	2																																																																																																																		1	2		2000.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	056	0	1	02	01	H4004_056_0	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		1500.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	065	0	1	02	01	H4004_065_0	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		2000.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	066	0	1	02	01	H4004_066_0	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		500.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	068	0	1	01	01	H4004_068_0	4	2				3		0	20	2				2		1	2																																																																																																																		1	2		1000.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2
H4004	070	0	1	02	01	H4004_070_0	4	2				3		0	20	2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		1000.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2
H4004	071	0	1	02	01	H4004_071_0	4	2				3		0	20	2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		1500.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2
H4004	072	1	1	01	01	H4004_072_1	4	2				2				2				2		1	2																																																																																																																		1	2		2000.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	072	2	1	01	01	H4004_072_2	4	2				2				2				2		1	2																																																																																																																		1	2		2000.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	072	3	1	01	01	H4004_072_3	4	2				2				2				2		1	2																																																																																																																		1	2		2000.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	073	1	1	02	01	H4004_073_1	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		1500.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	073	2	1	02	01	H4004_073_2	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		1500.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	073	3	1	02	01	H4004_073_3	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		1500.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	075	0	1	02	01	H4004_075_0	4	2				2				2				2		1	2	2							2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		2500.00	3		2		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	076	1	1	01	01	H4004_076_1	4	2				2				2				2		1	2																																																																																																																		1	2		2000.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	076	2	1	01	01	H4004_076_2	4	2				2				2				2		1	2																																																																																																																		1	2		2000.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	076	3	1	01	01	H4004_076_3	4	2				2				2				2		1	2																																																																																																																		1	2		1500.00	3				2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	817	0	1	02	01	H4004_817_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	818	0	1	02	01	H4004_818_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	819	0	1	02	01	H4004_819_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	820	0	1	02	01	H4004_820_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	822	0	1	02	01	H4004_822_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	823	0	1	02	01	H4004_823_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	824	0	1	02	01	H4004_824_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	825	0	1	02	01	H4004_825_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	826	0	1	02	01	H4004_826_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	827	0	1	02	01	H4004_827_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	828	0	1	02	01	H4004_828_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	829	0	1	02	01	H4004_829_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	830	0	1	02	01	H4004_830_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	831	0	1	02	01	H4004_831_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	832	0	1	02	01	H4004_832_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4004	833	0	1	02	01	H4004_833_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4005	004	0	1	04	01	H4005_004_0	9	2				2				2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA). One (1) every 6 months, for minors under 19 years and adults who have lost salivary function.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				2	2	1	2	2	1000.00	3		2		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H4005	801	0	1	04	01	H4005_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4005	802	0	1	04	01	H4005_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4005	804	0	1	04	01	H4005_804_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4005	808	0	1	04	01	H4005_808_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4005	809	0	1	04	01	H4005_809_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4005	810	0	1	04	01	H4005_810_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4005	812	0	1	04	01	H4005_812_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4026	001	0	1	01	01	H4026_001_0	11	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1500.00	3		2		2					2		2	1				1	25	25	25	2				2	2	2	1				1	25	25	25	2				2	2	2	1				1	25	25	25	2				2	2	2	1				1	25	25	25	2				2	2																															2	1				1	25	25	25	2				2	2	2	1				1	25	25	25	2				2	2																2	1				1	25	25	25	2				2	2
H4026	801	0	1	01	01	H4026_801_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4026	802	0	1	01	01	H4026_802_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4026	803	0	1	01	01	H4026_803_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4026	804	0	1	01	01	H4026_804_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4030	001	0	1	04	01	H4030_001_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4030	002	0	1	04	01	H4030_002_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H4030	005	0	1	04	01	H4030_005_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4030	026	0	1	04	01	H4030_026_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4032	001	0	1	02	01	H4032_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H4032	002	0	1	02	01	H4032_002_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H4032	003	0	1	02	01	H4032_003_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H4036	008	0	1	04	01	H4036_008_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H4036	017	0	1	04	01	H4036_017_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	022	0	1	04	01	H4036_022_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	024	0	1	04	01	H4036_024_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	025	0	1	04	01	H4036_025_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1200.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	026	0	1	04	01	H4036_026_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	034	0	1	04	01	H4036_034_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	036	0	1	04	01	H4036_036_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	040	0	1	04	01	H4036_040_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	801	0	1	04	01	H4036_801_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	802	0	1	04	01	H4036_802_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	805	0	1	04	01	H4036_805_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	806	0	2	04	01	H4036_806_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	807	0	1	04	01	H4036_807_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	809	0	2	04	01	H4036_809_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	810	0	2	04	01	H4036_810_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	812	0	1	04	01	H4036_812_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	813	0	1	04	01	H4036_813_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	814	0	1	04	01	H4036_814_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	819	0	1	04	01	H4036_819_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	820	0	1	04	01	H4036_820_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	821	0	2	04	01	H4036_821_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	822	0	2	04	01	H4036_822_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	823	0	1	04	01	H4036_823_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	824	0	1	04	01	H4036_824_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	825	0	2	04	01	H4036_825_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	826	0	2	04	01	H4036_826_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	827	0	1	04	01	H4036_827_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	828	0	1	04	01	H4036_828_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	829	0	2	04	01	H4036_829_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4036	830	0	2	04	01	H4036_830_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4045	001	0	1	01	01	H4045_001_0	8	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4053	001	0	1	20	08	H4053_001_0	1																																																																																																																																																																																																																																																																																																						
H4053	002	0	1	20	08	H4053_002_0	1																																																																																																																																																																																																																																																																																																						
H4054	001	0	1	01	01	H4054_001_0	7	2				1	20	20	20	2				2		1	2	1		4600.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4057	001	0	1	01	01	H4057_001_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4073	001	0	1	02	01	H4073_001_0	4	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H4073	003	0	1	02	01	H4073_003_0	5	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H4073	004	0	1	02	01	H4073_004_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H4074	001	0	1	20	08	H4074_001_0	1																																																																																																																																																																																																																																																																																																						
H4074	002	0	1	20	08	H4074_002_0	1																																																																																																																																																																																																																																																																																																						
H4086	001	0	1	04	01	H4086_001_0	10	2				2				3		0.00	25.00	2		2	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4086	002	0	1	04	01	H4086_002_0	10	2				1	20	20	20	2				2		2	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4091	001	0	1	04	01	H4091_001_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4091	002	0	1	04	01	H4091_002_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2																														
H4091	003	0	1	04	01	H4091_003_0	4	2				1	20	20	20	2				2		1	2	1	2	750.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2																															1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2																														
H4093	001	0	1	01	01	H4093_001_0	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4093	009	0	1	01	01	H4093_009_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4093	010	0	1	01	01	H4093_010_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4105	001	0	1	20	08	H4105_001_0	1																																																																																																																																																																																																																																																																																																						
H4105	002	0	1	20	08	H4105_002_0	1																																																																																																																																																																																																																																																																																																						
H4118	001	0	1	20	08	H4118_001_0	1																																																																																																																																																																																																																																																																																																						
H4118	002	0	1	20	08	H4118_002_0	1																																																																																																																																																																																																																																																																																																						
H4127	001	0	1	01	01	H4127_001_0	9	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2
H4127	002	0	1	01	01	H4127_002_0	9	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H4140	013	0	1	01	01	H4140_013_0	8	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	6	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or Plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	2	3		2				2				1	2	2	2	1	1		2				2				1	2	2	2	4	3		2				2				1	2																														
H4140	017	0	1	01	01	H4140_017_0	8	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	6	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or Plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2																2	2	3	3		2				2				1	2																														
H4140	020	0	1	01	01	H4140_020_0	8	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	5	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or Plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2																2	2	4	3		2				2				1	2																														
H4140	021	0	1	01	01	H4140_021_0	8	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	6	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or Plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2																2	2	3	3		2				2				1	2																														
H4140	022	0	1	01	01	H4140_022_0	9	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	2	3		2				2				1	2																2	2	4	3		2				2				1	2																														
H4140	023	0	1	01	01	H4140_023_0	9	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Periodontal root scaling and root planing - 1 per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2																2	2	4	3		2				2				1	2																														
H4140	024	0	1	01	01	H4140_024_0	8	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	7	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2	2	2	1	1		2				2				1	2	2	2	4	3		2				2				1	2																														
H4140	025	0	1	01	01	H4140_025_0	9	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Periodontal root scaling and root planing - 1 per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2																2	2	4	3		2				2				1	2																														
H4140	026	0	1	01	01	H4140_026_0	8	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																																														2	2	4	3		2				2				1	2																														
H4141	003	0	1	01	01	H4141_003_0	5	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4141	015	0	1	01	01	H4141_015_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4141	017	3	1	01	01	H4141_017_3	6	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4141	017	5	1	01	01	H4141_017_5	6	2				2				1	20.00	20.00	20.00	2		1	2	1		1750.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4141	022	0	1	01	01	H4141_022_0	6	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H4141	023	0	1	01	01	H4141_023_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4141	024	0	1	01	01	H4141_024_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4141	801	0	1	01	01	H4141_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4141	802	0	1	01	01	H4141_802_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4141	805	0	1	01	01	H4141_805_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4141	806	0	1	01	01	H4141_806_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4142	001	0	1	20	08	H4142_001_0	1																																																																																																																																																																																																																																																																																																						
H4142	002	0	1	20	08	H4142_002_0	1																																																																																																																																																																																																																																																																																																						
H4152	004	0	1	01	01	H4152_004_0	4	2				1	20	20	20	2				2		2	2	1		1500.00	3		2		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H4152	013	0	1	02	01	H4152_013_0	6	2				1	20	20	20	2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H4152	018	0	1	02	01	H4152_018_0	6	2				1	20	20	20	2				2		2	2	1		2500.00	3		2		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H4152	021	0	1	01	01	H4152_021_0	7	2				1	20	20	20	2				2		2	2	1		2500.00	3		2		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2																2	1				2				2				2	2																2	1				2				2				2	2
H4152	022	0	1	02	01	H4152_022_0	6	2				1	20	20	20	2				2		2	2	1		1500.00	3		2		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H4152	023	0	1	02	01	H4152_023_0	6	2				1	20	20	20	2				2		2	2	1		500.00	3		2		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																				
H4152	815	0	1	02	01	H4152_815_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4152	817	0	1	01	01	H4152_817_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4158	001	0	1	01	01	H4158_001_0	8	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4158	002	0	1	01	01	H4158_002_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H4158	003	0	1	01	01	H4158_003_0	5	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H4158	004	0	1	01	01	H4158_004_0	8	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4161	002	0	1	02	01	H4161_002_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		350.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	003	0	1	02	01	H4161_003_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	004	0	1	02	01	H4161_004_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		500.00	3		1	1	2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	1				2				2				2	2	2	1				2				2				2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		4	1				2				2				1	2	4	1				2				2				1	2	4	1				2				2				1	2	4	1				2				2				1	2																															2	1				2				2				1	2	4	1				2				2				1	2																4	1				2				2				1	2
H4161	005	0	1	02	01	H4161_005_0	4	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H4161	006	0	1	02	01	H4161_006_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H4161	007	0	1	02	01	H4161_007_0	4	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H4161	009	0	1	02	01	H4161_009_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		200.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	011	0	1	02	01	H4161_011_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	012	0	1	02	01	H4161_012_0	4	2				2				3		0.00	20.00	2		1	2	1		1200.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	013	0	1	02	01	H4161_013_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	014	0	1	02	01	H4161_014_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		4000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4161	015	0	1	02	01	H4161_015_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		4000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4161	016	0	1	02	01	H4161_016_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		4000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4161	017	0	1	02	01	H4161_017_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		4000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4172	001	0	1	01	01	H4172_001_0	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H4172	003	0	1	01	01	H4172_003_0	8	2				1	20	20	20	2				2		1	2	1		3400.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H4185	001	0	1	20	08	H4185_001_0	1																																																																																																																																																																																																																																																																																																						
H4185	002	0	1	20	08	H4185_002_0	1																																																																																																																																																																																																																																																																																																						
H4193	001	0	1	01	01	H4193_001_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4203	001	0	1	20	08	H4203_001_0	1																																																																																																																																																																																																																																																																																																						
H4203	002	0	1	20	08	H4203_002_0	1																																																																																																																																																																																																																																																																																																						
H4213	019	0	1	09	04	H4213_019_0	2	2				2				1	40.00	40.00	40.00	2				2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	2	2	3000.00	3		2		2					2		2	2	1	3		1	20	20	20	2																					2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2						2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2																																																			2	1				1	20	20	20	2																																			
H4213	020	0	1	09	04	H4213_020_0	3	2				2				1	40.00	40.00	40.00	2				2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	2	2	3000.00	3		2		2					2		2	2	1	3		1	20	20	20	2																					2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2						2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2																																																			2	1				1	20	20	20	2																																			
H4213	801	0	1	09	04	H4213_801_0	1	2				3		20	20	2				2																																																																																																																																																																																																																																																																																									
H4213	802	0	1	09	04	H4213_802_0	1	2				3		20	20	2				2																																																																																																																																																																																																																																																																																									
H4213	803	0	1	09	04	H4213_803_0	1	2				3		20	20	2				2																																																																																																																																																																																																																																																																																									
H4213	804	0	1	09	04	H4213_804_0	1	2				3		20	20	2				2																																																																																																																																																																																																																																																																																									
H4227	001	0	1	01	01	H4227_001_0	6	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		3250.00	3		2		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Pre and post-op radiographs required. Prior authorization required. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 months. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H4227	002	0	1	01	01	H4227_002_0	6	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		4750.00	3		2		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Pre and post-op radiographs required. Prior authorization required. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 months. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H4232	001	0	1	01	01	H4232_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4232	003	0	1	01	01	H4232_003_0	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4235	001	0	1	20	08	H4235_001_0	1																																																																																																																																																																																																																																																																																																						
H4235	002	0	1	20	08	H4235_002_0	1																																																																																																																																																																																																																																																																																																						
H4256	001	0	1	20	08	H4256_001_0	1																																																																																																																																																																																																																																																																																																						
H4256	002	0	1	20	08	H4256_002_0	1																																																																																																																																																																																																																																																																																																						
H4279	007	1	1	01	01	H4279_007_1	9	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every six months. A panoramic x-ray is offered at a periodicity of 1 every 60 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		4500.00	3				2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H4279	007	2	1	01	01	H4279_007_2	9	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every six months. A panoramic x-ray is offered at a periodicity of 1 every 60 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		4500.00	3				2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H4279	007	3	1	01	01	H4279_007_3	9	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every six months. A panoramic x-ray is offered at a periodicity of 1 every 60 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		4500.00	3				2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H4279	007	4	1	01	01	H4279_007_4	9	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every six months. A panoramic x-ray is offered at a periodicity of 1 every 60 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		3500.00	3				2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H4286	001	0	1	01	01	H4286_001_0	10	2				2				2				2		1	1	1		10300.00	3		2		2				2					2					2		2	2	1	4		2				2				1	1	2	2	1	4		2				2				1	1	2	1				2				2				1	1	2	2	1	4		2				2				1	1	2	2	1	3		2				2				1	1	2	1				2				2				1	1	1	1							2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	2	2	3		2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H4286	002	0	1	01	01	H4286_002_0	10	2				2				2				2		1	1	1		5050.00	3		2		2				2					2					2		2	2	1	4		2				2				1	1	2	2	1	4		2				2				1	1	2	1				2				2				1	1	2	2	1	4		2				2				1	1	2	2	1	3		2				2				1	1	2	1				2				2				1	1	1	1							2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	2	2	3		2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H4286	003	0	1	01	01	H4286_003_0	10	2				2				2				2		1	1	1		5600.00	3		2		2				2					2					2		2	2	1	4		2				2				1	1	2	2	1	4		2				2				1	1	2	1				2				2				1	1	2	2	1	4		2				2				1	1	2	2	1	3		2				2				1	1	2	1				2				2				1	1	1	1							2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	2	2	3		2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H4286	005	0	1	01	01	H4286_005_0	10	2				2				2				2		1	1	1		5050.00	3		2		2				2					2					2		2	2	1	4		2				2				1	1	2	2	1	4		2				2				1	1	2	1				2				2				1	1	2	2	1	4		2				2				1	1	2	2	1	3		2				2				1	1	2	1				2				2				1	1	1	1							2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	2	2	3		2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H4305	001	0	1	20	08	H4305_001_0	1																																																																																																																																																																																																																																																																																																						
H4305	002	0	1	20	08	H4305_002_0	1																																																																																																																																																																																																																																																																																																						
H4326	001	0	1	20	08	H4326_001_0	1																																																																																																																																																																																																																																																																																																						
H4326	002	0	1	20	08	H4326_002_0	1																																																																																																																																																																																																																																																																																																						
H4329	001	0	1	01	01	H4329_001_0	4	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	1 other diagnostic/visit	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	perio debride 1/yr, perio maint, scaling for mod inflammation, scaling/root planing, splint unl/yr	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4346	001	0	1	02	01	H4346_001_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1800.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4346	005	0	1	02	01	H4346_005_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	006	0	1	02	01	H4346_006_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	010	0	1	01	01	H4346_010_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1750.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	012	0	1	02	01	H4346_012_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H4346	014	0	1	01	01	H4346_014_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	017	0	1	02	01	H4346_017_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4346	025	0	1	01	01	H4346_025_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	030	0	1	02	01	H4346_030_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	031	0	1	01	01	H4346_031_0	5	2				1	20	20	20	2				2		1	2	1		2250.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	037	0	1	02	01	H4346_037_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	805	0	1	01	01	H4346_805_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4346	806	0	2	01	01	H4346_806_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4346	809	0	1	01	01	H4346_809_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4346	810	0	2	01	01	H4346_810_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4346	812	0	1	01	01	H4346_812_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4346	821	0	2	01	01	H4346_821_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4346	823	0	1	01	01	H4346_823_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4346	824	0	1	01	01	H4346_824_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4346	826	0	1	01	01	H4346_826_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4346	827	0	2	01	01	H4346_827_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4346	828	0	2	01	01	H4346_828_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4346	830	0	2	01	01	H4346_830_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4348	001	0	1	04	01	H4348_001_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4348	002	0	1	04	01	H4348_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H4348	003	0	1	04	01	H4348_003_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4348	004	0	1	04	01	H4348_004_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4348	005	0	1	04	01	H4348_005_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4348	006	0	1	04	01	H4348_006_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H4348	007	0	1	04	01	H4348_007_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4348	020	0	1	04	01	H4348_020_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4348	021	0	1	04	01	H4348_021_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4348	022	0	1	04	01	H4348_022_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4348	023	0	1	04	01	H4348_023_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4367	001	0	1	01	01	H4367_001_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H4367	002	0	1	01	01	H4367_002_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H4371	001	0	1	01	01	H4371_001_0	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4393	001	0	1	20	08	H4393_001_0	1																																																																																																																																																																																																																																																																																																						
H4393	002	0	1	20	08	H4393_002_0	1																																																																																																																																																																																																																																																																																																						
H4402	001	0	1	20	08	H4402_001_0	1																																																																																																																																																																																																																																																																																																						
H4402	002	0	1	20	08	H4402_002_0	1																																																																																																																																																																																																																																																																																																						
H4407	004	0	1	01	01	H4407_004_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	011	0	1	01	01	H4407_011_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		750.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	027	0	1	01	01	H4407_027_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		2050.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	029	0	1	01	01	H4407_029_0	5	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	030	1	1	01	01	H4407_030_1	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1950.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	030	2	1	01	01	H4407_030_2	6	2				2				1	10.00	10.00	10.00	2		1	2	1		2100.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	030	3	1	01	01	H4407_030_3	6	2				2				1	15.00	15.00	15.00	2		1	2	1		1750.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	033	0	1	01	01	H4407_033_0	8	2				2				1	10.00	10.00	10.00	2		1	2	1		1200.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	034	0	1	01	01	H4407_034_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4439	001	0	1	01	01	H4439_001_0	6	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4439	004	0	1	01	01	H4439_004_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4439	005	0	1	01	01	H4439_005_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4444	001	0	1	01	01	H4444_001_0	7	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4444	003	0	1	01	01	H4444_003_0	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4444	004	0	1	01	01	H4444_004_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4445	001	0	1	20	08	H4445_001_0	1																																																																																																																																																																																																																																																																																																						
H4445	002	0	1	20	08	H4445_002_0	1																																																																																																																																																																																																																																																																																																						
H4461	004	0	1	01	01	H4461_004_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4461	022	0	1	01	01	H4461_022_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	025	0	1	01	01	H4461_025_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	038	0	1	01	01	H4461_038_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	0.00	0.00	0.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H4461	039	0	1	01	01	H4461_039_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	042	0	1	01	01	H4461_042_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	043	1	1	01	01	H4461_043_1	4	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	043	2	1	01	01	H4461_043_2	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	044	0	1	02	01	H4461_044_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	045	0	1	01	01	H4461_045_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4461	046	0	1	01	01	H4461_046_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4461	047	0	1	02	01	H4461_047_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	048	0	1	02	01	H4461_048_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4461	049	0	1	01	01	H4461_049_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	050	0	1	01	01	H4461_050_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4461	051	0	1	01	01	H4461_051_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	052	0	1	01	01	H4461_052_0	4	2				2				1	20.00	20.00	20.00	2		1	1	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H4461	053	0	1	01	01	H4461_053_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	054	0	1	01	01	H4461_054_0	4	2				2				1	25.00	25.00	25.00	2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H4461	055	0	1	01	01	H4461_055_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	056	0	1	01	01	H4461_056_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	057	0	1	01	01	H4461_057_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	058	0	1	01	01	H4461_058_0	4	2				2				1	20.00	20.00	20.00	2		1	1	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	059	0	1	01	01	H4461_059_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	060	0	1	01	01	H4461_060_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H4461	061	0	1	01	01	H4461_061_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	062	0	1	01	01	H4461_062_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	063	0	1	01	01	H4461_063_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	064	0	1	01	01	H4461_064_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	065	0	1	01	01	H4461_065_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4461	066	0	1	01	01	H4461_066_0	4	2				2				1	10.00	10.00	10.00	2		1	1	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H4461	067	0	1	01	01	H4461_067_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	068	0	1	01	01	H4461_068_0	5	2				2				1	15.00	15.00	15.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H4461	069	0	1	01	01	H4461_069_0	4	2				1	20	20	20	2				2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	070	0	1	01	01	H4461_070_0	4	2				1	20	20	20	2				2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	071	0	1	01	01	H4461_071_0	4	2				1	20	20	20	2				2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	072	0	1	01	01	H4461_072_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	073	0	1	01	01	H4461_073_0	4	2				2				1	5.00	5.00	5.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	074	0	1	01	01	H4461_074_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	075	0	1	01	01	H4461_075_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4461	076	0	1	01	01	H4461_076_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	077	0	1	01	01	H4461_077_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	078	0	1	01	01	H4461_078_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	079	0	1	01	01	H4461_079_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H4461	080	1	1	01	01	H4461_080_1	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4461	080	2	1	01	01	H4461_080_2	4	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4461	081	1	1	01	01	H4461_081_1	4	2				2				1	20.00	20.00	20.00	2		1	2	1		4000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4461	081	2	1	01	01	H4461_081_2	4	2				2				1	20.00	20.00	20.00	2		1	2	1		5000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	082	0	1	01	01	H4461_082_0	4	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H4461	083	1	1	01	01	H4461_083_1	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4461	083	2	1	01	01	H4461_083_2	4	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	084	0	1	01	01	H4461_084_0	4	2				2				1	25.00	25.00	25.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H4461	085	0	1	01	01	H4461_085_0	4	2				1	20	20	20	2				2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	806	0	1	01	01	H4461_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4461	807	0	1	01	01	H4461_807_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4461	810	0	1	01	01	H4461_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4461	811	0	1	01	01	H4461_811_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4471	005	0	1	01	01	H4471_005_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4471	010	1	1	01	01	H4471_010_1	5	2				1	20	20	20	2				2		1	2	1		4000.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4471	010	2	1	01	01	H4471_010_2	5	2				1	20	20	20	2				2		1	2	1		3000.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4471	011	0	1	01	01	H4471_011_0	5	2				1	20	20	20	2				2		1	2	1		1400.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4473	001	0	1	04	01	H4473_001_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4473	002	0	1	04	01	H4473_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H4473	003	0	1	04	01	H4473_003_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4473	004	0	1	04	01	H4473_004_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4473	007	0	1	04	01	H4473_007_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4473	011	0	1	04	01	H4473_011_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4473	014	0	1	04	01	H4473_014_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4490	001	0	1	01	01	H4490_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4490	003	0	1	01	01	H4490_003_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4497	001	1	1	04	01	H4497_001_1	8	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																				
H4497	001	3	1	04	01	H4497_001_3	8	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																				
H4497	002	1	1	04	01	H4497_002_1	8	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																				
H4497	002	3	1	04	01	H4497_002_3	8	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																				
H4497	003	1	1	04	01	H4497_003_1	7	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	1				1	30	30	30	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																																													2	1				1	30	30	30	2				2	2																2	1				1	30	30	30	2				2	2
H4497	003	3	1	04	01	H4497_003_3	7	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	1				1	30	30	30	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																																													2	1				1	30	30	30	2				2	2																2	1				1	30	30	30	2				2	2
H4497	006	0	1	04	01	H4497_006_0	8	2				1	0	0	0	2				2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																																													2	1				2				2				2	2																2	1				2				2				2	2
H4497	801	0	1	04	01	H4497_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4497	802	0	1	04	01	H4497_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4497	803	0	1	04	01	H4497_803_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4499	001	0	1	01	01	H4499_001_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	6	2 of periodic oral evaluation every 12 months1 comprehensive evaluation per provider/location per 36 months3 of  limited oral evaluation every 12 months	2				2				2	2	2	2	1	6	Please see notes section for description of x-ray coverage	2				2				2	2																2	2	2	6	2 visits/12 months	2				2				2	2	2	2	2	6	2 fluoride treatments per 12 months	2				2				2	2																1	2		4000.00	3		2		2					2		2	2	1	6	Please see notes section for description of restorative services	2				2				1	2	2	2	1	6	Please see notes section for description of endodontics services	2				2				1	2	2	2	1	6	Please see notes section for description of periodontics services	2				2				1	2	2	2	1	6	Please see notes section for description of prosthodontics services	2				2				1	2																																														2	1				2				2				1	2																2	1				2				2				1	2
H4506	003	0	1	02	01	H4506_003_0	4	2				2				1	5.00	5.00	5.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H4513	009	0	1	01	01	H4513_009_0	7	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	026	0	1	01	01	H4513_026_0	8	2				2				1	25.00	25.00	25.00	2		1	2	1		1900.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	027	0	1	01	01	H4513_027_0	8	2				2				2				2		1	2	1		2450.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	030	0	1	01	01	H4513_030_0	9	2				2				1	25.00	25.00	25.00	2		1	2	1		1200.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	033	0	1	01	01	H4513_033_0	8	2				2				1	30.00	30.00	30.00	2		1	2	1		1200.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	034	0	1	01	01	H4513_034_0	9	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	035	0	1	01	01	H4513_035_0	9	2				2				2				2		1	2	1		2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	036	0	1	02	01	H4513_036_0	9	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	037	0	1	01	01	H4513_037_0	9	2				2				1	25.00	25.00	25.00	2		1	2	1		1900.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	038	0	1	01	01	H4513_038_0	10	2				2				1	25.00	25.00	25.00	2		1	2	1		1650.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	039	0	1	01	01	H4513_039_0	9	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	045	0	1	01	01	H4513_045_0	7	2				2				1	25.00	25.00	25.00	2		1	2	1		750.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	049	1	1	01	01	H4513_049_1	8	2				2				1	20.00	20.00	20.00	2		1	2	1		1600.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	049	2	1	01	01	H4513_049_2	9	2				2				1	20.00	20.00	20.00	2		1	2	1		1700.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	049	3	1	01	01	H4513_049_3	9	2				2				1	25.00	25.00	25.00	2		1	2	1		1450.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	049	4	1	01	01	H4513_049_4	8	2				2				1	15.00	15.00	15.00	2		1	2	1		2100.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	049	5	1	01	01	H4513_049_5	8	2				2				1	15.00	15.00	15.00	2		1	2	1		1700.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	050	0	1	01	01	H4513_050_0	8	2				2				1	20.00	20.00	20.00	2		1	2	1		1600.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	052	0	1	01	01	H4513_052_0	8	2				2				1	20.00	20.00	20.00	2		1	2	1		1900.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	053	0	1	01	01	H4513_053_0	8	2				2				2				2		1	2	1		1500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	060	1	1	01	01	H4513_060_1	8	2				2				2				2		1	2	1		2400.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	060	2	1	01	01	H4513_060_2	8	2				2				2				2		1	2	1		2500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	060	3	1	01	01	H4513_060_3	8	2				2				2				2		1	2	1		2500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	060	4	1	01	01	H4513_060_4	8	2				2				2				2		1	2	1		2500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	060	5	1	01	01	H4513_060_5	8	2				2				2				2		1	2	1		2500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	061	1	1	01	01	H4513_061_1	9	2				2				1	20.00	20.00	20.00	2		1	2	1		2750.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	061	2	1	01	01	H4513_061_2	9	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	061	3	1	01	01	H4513_061_3	9	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	061	4	1	01	01	H4513_061_4	8	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	061	5	1	01	01	H4513_061_5	8	2				2				1	15.00	15.00	15.00	2		1	2	1		5000.00	3				2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	061	6	1	01	01	H4513_061_6	9	2				2				1	10.00	10.00	10.00	2		1	2	1		3100.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	064	0	1	01	01	H4513_064_0	9	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	068	1	1	01	01	H4513_068_1	10	2				2				1	45.00	45.00	45.00	2		1	2	1		650.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	068	2	1	01	01	H4513_068_2	9	2				2				1	40.00	40.00	40.00	2		1	2	1		600.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	073	0	1	01	01	H4513_073_0	9	2				2				1	35.00	35.00	35.00	2		1	2	1		900.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	075	0	1	01	01	H4513_075_0	8	2				2				2				2		1	2	1		2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	077	1	1	01	01	H4513_077_1	8	2				2				1	10.00	10.00	10.00	2		1	2	1		1600.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	077	2	1	01	01	H4513_077_2	8	2				2				1	10.00	10.00	10.00	2		1	2	1		1450.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	077	3	1	01	01	H4513_077_3	8	2				2				1	10.00	10.00	10.00	2		1	2	1		1800.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	077	4	1	01	01	H4513_077_4	8	2				2				1	15.00	15.00	15.00	2		1	2	1		1900.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	078	0	1	01	01	H4513_078_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	079	0	1	01	01	H4513_079_0	8	2				1	20	20	20	2				2		1	2	1		3300.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	080	0	1	01	01	H4513_080_0	8	2				2				2				2		1	2	1		2300.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	081	0	1	01	01	H4513_081_0	8	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	083	1	1	01	01	H4513_083_1	11	2				2				1	40.00	40.00	40.00	2		1	2	1		5000.00	3				2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	083	2	1	01	01	H4513_083_2	11	2				2				1	40.00	40.00	40.00	2		1	2	1		2300.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	083	3	1	01	01	H4513_083_3	11	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	083	4	1	01	01	H4513_083_4	9	2				2				1	35.00	35.00	35.00	2		1	2	1		5000.00	3				2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	083	5	1	01	01	H4513_083_5	9	2				2				1	45.00	45.00	45.00	2		1	2	1		5000.00	3				2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	083	6	1	01	01	H4513_083_6	9	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	083	7	1	01	01	H4513_083_7	9	2				2				1	45.00	45.00	45.00	2		1	2	1		5000.00	3				2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	084	0	1	02	01	H4513_084_0	8	2				2				1	20.00	20.00	20.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	085	0	1	01	01	H4513_085_0	10	2				2				1	20.00	20.00	20.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	086	0	1	01	01	H4513_086_0	10	2				2				1	25.00	25.00	25.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	087	1	1	01	01	H4513_087_1	8	2				2				1	10.00	10.00	10.00	2		1	2	1		1800.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	087	2	1	01	01	H4513_087_2	8	2				2				1	10.00	10.00	10.00	2		1	2	1		2050.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	087	3	1	01	01	H4513_087_3	8	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	087	4	1	01	01	H4513_087_4	8	2				2				1	10.00	10.00	10.00	2		1	2	1		1550.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	088	0	1	01	01	H4513_088_0	10	2				2				1	35.00	35.00	35.00	2		1	2	1		600.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	089	0	1	01	01	H4513_089_0	10	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	090	0	1	01	01	H4513_090_0	8	2				2				1	55.00	55.00	55.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	091	0	1	01	01	H4513_091_0	9	2				2				1	45.00	45.00	45.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	092	0	1	01	01	H4513_092_0	9	2				2				1	45.00	45.00	45.00	2		1	2	1		1100.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	093	0	1	01	01	H4513_093_0	9	2				2				1	50.00	50.00	50.00	2		1	2	1		850.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	094	0	1	01	01	H4513_094_0	8	2				2				1	20.00	20.00	20.00	2		1	2	1		1100.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	095	0	1	01	01	H4513_095_0	9	2				2				1	15.00	15.00	15.00	2		1	2	1		1100.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	096	0	1	02	01	H4513_096_0	10	2				2				1	5.00	5.00	5.00	2		1	2	1		2700.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	097	0	1	01	01	H4513_097_0	8	2				2				1	15.00	15.00	15.00	2		1	2	1		1250.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	098	0	1	01	01	H4513_098_0	9	2				2				1	10.00	10.00	10.00	2		1	2	1		1150.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	103	0	1	01	01	H4513_103_0	9	2				2				1	25.00	25.00	25.00	2		1	2	1		2350.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	104	0	1	01	01	H4513_104_0	9	2				2				2				2		1	2	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	105	0	1	01	01	H4513_105_0	11	2				2				2				2		1	2	1		3500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	106	0	1	01	01	H4513_106_0	8	2				2				1	30.00	30.00	30.00	2		1	2	1		550.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	108	0	1	01	01	H4513_108_0	8	2				2				1	40.00	40.00	40.00	2		1	2	1		850.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	109	1	1	01	01	H4513_109_1	8	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	109	2	1	01	01	H4513_109_2	8	2				2				1	10.00	10.00	10.00	2		1	2	1		1250.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	110	1	1	01	01	H4513_110_1	8	2				2				2				2		1	2	1		3500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	110	2	1	01	01	H4513_110_2	8	2				2				2				2		1	2	1		2000.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	804	0	1	01	01	H4513_804_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4513	815	0	1	01	01	H4513_815_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4513	817	0	1	01	01	H4513_817_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4513	819	0	1	01	01	H4513_819_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4513	821	0	1	01	01	H4513_821_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4514	007	0	1	02	01	H4514_007_0	5	2				1	20	20	20	2				2		1	2																																																																																																																		2								2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H4514	014	0	1	02	01	H4514_014_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4514	015	0	1	02	01	H4514_015_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4514	017	0	1	02	01	H4514_017_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4514	022	0	1	02	01	H4514_022_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4514	023	0	1	02	01	H4514_023_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H4514	801	0	1	01	01	H4514_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4514	803	0	1	01	01	H4514_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4514	806	0	1	01	01	H4514_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4517	001	0	1	20	08	H4517_001_0	1																																																																																																																																																																																																																																																																																																						
H4517	002	0	1	20	08	H4517_002_0	1																																																																																																																																																																																																																																																																																																						
H4518	001	0	1	20	08	H4518_001_0	1																																																																																																																																																																																																																																																																																																						
H4518	002	0	1	20	08	H4518_002_0	1																																																																																																																																																																																																																																																																																																						
H4523	001	0	1	01	01	H4523_001_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	015	0	1	01	01	H4523_015_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	020	0	1	01	01	H4523_020_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	021	0	1	01	01	H4523_021_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	024	0	1	01	01	H4523_024_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	027	0	1	01	01	H4523_027_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	028	0	1	01	01	H4523_028_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	029	0	1	01	01	H4523_029_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	030	0	1	01	01	H4523_030_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	031	0	1	01	01	H4523_031_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	034	0	1	01	01	H4523_034_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	037	0	1	01	01	H4523_037_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	038	0	1	01	01	H4523_038_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	039	0	1	01	01	H4523_039_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	041	0	1	01	01	H4523_041_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	042	0	1	01	01	H4523_042_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	043	0	1	01	01	H4523_043_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	044	0	1	01	01	H4523_044_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	045	0	1	01	01	H4523_045_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	047	0	1	01	01	H4523_047_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4523	048	0	1	01	01	H4523_048_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	049	0	1	01	01	H4523_049_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	050	0	1	01	01	H4523_050_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	051	0	1	01	01	H4523_051_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	801	0	1	01	01	H4523_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4523	802	0	1	01	01	H4523_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4523	805	0	1	01	01	H4523_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4527	001	0	1	02	01	H4527_001_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4527	002	0	1	02	01	H4527_002_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4527	003	0	1	02	01	H4527_003_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	005	0	1	02	01	H4527_005_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	013	0	1	02	01	H4527_013_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	024	0	1	02	01	H4527_024_0	2	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4527	037	0	1	02	01	H4527_037_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4527	039	0	1	02	01	H4527_039_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4527	040	0	1	02	01	H4527_040_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	041	0	1	02	01	H4527_041_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	042	0	1	02	01	H4527_042_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	045	0	1	02	01	H4527_045_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	048	0	1	02	01	H4527_048_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4527	051	0	1	02	01	H4527_051_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4527	052	0	1	02	01	H4527_052_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	053	0	1	02	01	H4527_053_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4527	055	0	1	02	01	H4527_055_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	056	0	1	02	01	H4527_056_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	057	0	1	02	01	H4527_057_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H4527	058	0	1	02	01	H4527_058_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	059	0	1	02	01	H4527_059_0	7	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4527	060	1	1	02	01	H4527_060_1	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H4527	060	2	1	02	01	H4527_060_2	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H4527	061	0	1	02	01	H4527_061_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H4527	801	0	1	01	01	H4527_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4527	802	0	1	01	01	H4527_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4527	803	0	1	01	01	H4527_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4537	801	0	1	04	01	H4537_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4538	003	0	1	20	08	H4538_003_0	1																																																																																																																																																																																																																																																																																																						
H4538	004	0	1	20	08	H4538_004_0	1																																																																																																																																																																																																																																																																																																						
H4544	801	0	1	04	01	H4544_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4545	001	0	1	20	08	H4545_001_0	4																																																																																																																																																																																																																																																																																																						
H4545	002	0	1	20	08	H4545_002_0	7																																																																																																																																																																																																																																																																																																						
H4604	003	0	1	02	01	H4604_003_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4604	005	0	1	02	01	H4604_005_0	2	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4604	011	0	1	02	01	H4604_011_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4604	012	0	1	02	01	H4604_012_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4604	013	0	1	02	01	H4604_013_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4604	014	0	1	02	01	H4604_014_0	6	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4604	016	0	1	02	01	H4604_016_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4604	017	0	1	02	01	H4604_017_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4604	018	0	1	02	01	H4604_018_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4604	019	0	1	02	01	H4604_019_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4604	020	0	1	02	01	H4604_020_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4604	022	0	1	02	01	H4604_022_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4604	024	0	1	02	01	H4604_024_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4604	025	0	1	02	01	H4604_025_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4604	026	0	1	02	01	H4604_026_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H4604	027	0	1	02	01	H4604_027_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4604	028	0	1	02	01	H4604_028_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4604	033	0	1	02	01	H4604_033_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4604	034	0	1	02	01	H4604_034_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4604	036	0	1	02	01	H4604_036_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H4604	037	0	1	02	01	H4604_037_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H4604	801	0	1	01	01	H4604_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4604	803	0	1	01	01	H4604_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4604	805	0	1	01	01	H4604_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4604	809	0	1	01	01	H4604_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4604	810	0	1	01	01	H4604_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4604	811	0	1	01	01	H4604_811_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4605	002	0	1	04	01	H4605_002_0	8	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1250.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H4605	004	0	1	04	01	H4605_004_0	8	2				2				1	30.00	30.00	30.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H4605	801	0	1	04	01	H4605_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4605	802	0	1	04	01	H4605_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4610	001	0	1	01	01	H4610_001_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4610	002	0	1	01	01	H4610_002_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4623	001	0	1	02	01	H4623_001_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4623	002	0	1	02	01	H4623_002_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H4624	001	0	1	01	01	H4624_001_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	003	0	1	01	01	H4624_003_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	006	0	1	01	01	H4624_006_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	010	0	1	01	01	H4624_010_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	011	0	1	01	01	H4624_011_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	012	0	1	01	01	H4624_012_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	022	0	1	01	01	H4624_022_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	023	0	1	01	01	H4624_023_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	025	0	1	01	01	H4624_025_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	026	0	1	01	01	H4624_026_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	027	0	1	01	01	H4624_027_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	028	0	1	01	01	H4624_028_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	029	0	1	01	01	H4624_029_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	031	0	1	01	01	H4624_031_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	032	0	1	01	01	H4624_032_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	033	0	1	01	01	H4624_033_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	034	0	1	01	01	H4624_034_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	036	0	1	01	01	H4624_036_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	037	0	1	01	01	H4624_037_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	038	0	1	01	01	H4624_038_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	039	0	1	01	01	H4624_039_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	040	0	1	01	01	H4624_040_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	042	0	1	01	01	H4624_042_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	043	0	1	01	01	H4624_043_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	044	0	1	01	01	H4624_044_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	045	0	1	01	01	H4624_045_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	046	0	1	01	01	H4624_046_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	047	0	1	01	01	H4624_047_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	048	0	1	01	01	H4624_048_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	049	0	1	01	01	H4624_049_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4626	001	0	1	20	08	H4626_001_0	1																																																																																																																																																																																																																																																																																																						
H4626	002	0	1	20	08	H4626_002_0	1																																																																																																																																																																																																																																																																																																						
H4647	001	0	1	01	01	H4647_001_0	5	2				2				2				2		1	1	2							2				2					2					2		2	2	2	3		2				2				1	1	2	2	1	6	Two periapical and one set of bitewing x-rays every year.	2				2				1	1	2	2	1	2		2				2				1	1	2	2	2	3		2				2				1	1	2	2	2	3		2				2				1	1	2	2	1	3		2				2				1	1	2								2					2		2	2	2	3		2				3		7.00	410.00	1	1	2	2	2	3		2				3		12.00	154.00	1	1	2	2	1	1		2				3		0.00	130.00	1	1	2	2	1	6	Dentures are limited to one per arch every 5 calendar years. Other limitations vary by code, ranging from once per year (Repair broken complete denture base - maxillary/mandibular) to once every 2 years (Rebase complete denture - maxillary/mandibular).	2				3		16.00	656.00	1	1																															2	2	1	6	Pontics and retainer inlay/onlay/crowns are limited to one per tooth every 5 calendar years. Some procedures such as re-cementing or re-bonding of partial dentures are limited to once per two years.	2				3		42.00	412.00	1	1	2	2	1	6	Extractions are limited to three procedures per year. Specified surgeries are limited to once per site per lifetime.	2				3		3.00	152.00	1	1																2	2	1	6	Limitations vary by code. Palliative treatment for dental pain is limited to one per day and limited occlusal adjustments are covered once every 5 calendar years.	2				3		0.00	18.00	1	1
H4647	002	0	1	01	01	H4647_002_0	5	2				2				2				2		1	1	2							2				2					2					2		2	2	2	3		2				2				1	1	2	2	1	6	Two periapical and one set of bitewing x-rays every year.	2				2				1	1	2	2	1	2		2				2				1	1	2	2	2	3		2				2				1	1	2	2	2	3		2				2				1	1	2	2	1	3		2				2				1	1	2								2					2		2	2	2	3		2				3		7.00	410.00	1	1	2	2	2	3		2				3		12.00	154.00	1	1	2	2	1	1		2				3		0.00	130.00	1	1	2	2	1	6	Dentures are limited to one per arch every 5 calendar years. Other limitations vary by code, ranging from once per year (Repair broken complete denture base - maxillary/mandibular) to once every 2 years (Rebase complete denture - maxillary/mandibular).	2				3		16.00	656.00	1	1																															2	2	1	6	Pontics and retainer inlay/onlay/crowns are limited to one per tooth every 5 calendar years. Some procedures such as re-cementing or re-bonding of partial dentures are limited to once per two years.	2				3		42.00	412.00	1	1	2	2	1	6	Extractions are limited to three procedures per year. Specified surgeries are limited to once per site per lifetime.	2				3		3.00	152.00	1	1																2	2	1	6	Limitations vary by code. Palliative treatment for dental pain is limited to one per day and limited occlusal adjustments are covered once every 5 calendar years.	2				3		0.00	18.00	1	1
H4647	801	0	1	01	01	H4647_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H4661	001	0	1	02	01	H4661_001_0	4	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H4661	003	0	1	02	01	H4661_003_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H4661	005	0	1	02	01	H4661_005_0	5	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H4676	001	0	1	01	01	H4676_001_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	1 Complete series of oral x-rays every 36 months1 Bitewing x-rays per calendar year2 Intraoral  occlusal radiographic image every calendar year	2				2				1	2																2	2	2	6	2 prophylaxis treatments per calendar year 1 periodontal scaling per quadrant per 24 months 2 periodontal maintenance per calendar year	2				2				1	2	2	2	1	3		2				2				2	2																1	1							2					2		2	2	1	6	See notes below.	2				2				1	2	2	2	1	6	See notes below.	2				2				1	2	2	2	1	6	See notes below.	2				2				1	2	2	2	1	6	See notes below	2				2				1	2																															2	2	1	6	See notes below	2				2				1	2	2	2	1	6	See notes below.	2				2				1	2																2	2	1	6	See notes below.	2				2				1	2
H4676	002	0	1	01	01	H4676_002_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	1 Complete series of oral x-rays every 36 months1 Bitewing x-rays per calendar year2 Intraoral  occlusal radiographic image every calendar year	2				2				1	2																2	2	2	6	2 prophylaxis treatments per calendar year 1 periodontal scaling per quadrant per 24 months 2 periodontal maintenance per calendar year	2				2				1	2	2	2	1	3		2				2				2	2																1	1							2					2		2	2	1	6	See notes below.	2				2				1	2	2	2	1	6	See notes below.	2				2				1	2	2	2	1	6	See notes below.	2				2				1	2	2	2	1	6	See notes below	2				2				1	2																															2	2	1	6	See notes below	2				2				1	2	2	2	1	6	See notes below.	2				2				1	2																2	2	1	6	See notes below.	2				2				1	2
H4694	002	0	1	01	01	H4694_002_0	5	2				1	20	20	20	2				2		1	2	1		2250.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4694	003	0	1	01	01	H4694_003_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4694	004	0	1	01	01	H4694_004_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4711	002	0	1	01	01	H4711_002_0	4	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4711	011	0	1	01	01	H4711_011_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H4711	014	0	1	01	01	H4711_014_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H4711	801	0	1	01	01	H4711_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4714	001	0	1	20	08	H4714_001_0	1																																																																																																																																																																																																																																																																																																						
H4714	002	0	1	20	08	H4714_002_0	1																																																																																																																																																																																																																																																																																																						
H4733	001	0	1	01	01	H4733_001_0	7	2				1	20	20	20	2				2		1	2																																																																																																																		1	2		2500.00	3		2		2					2																																															2	1				2				2				2	2																2	1				2				2				2	2																																																												
H4739	001	0	1	01	01	H4739_001_0	6	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		2000.00	3		2		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Pre and post-op radiographs required. Prior authorization required. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 months. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H4808	001	0	1	04	01	H4808_001_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4808	002	0	1	04	01	H4808_002_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4808	003	0	1	04	01	H4808_003_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H4808	004	0	1	04	01	H4808_004_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4808	005	0	1	04	01	H4808_005_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H4835	002	0	1	01	01	H4835_002_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4835	801	0	1	01	01	H4835_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4847	001	0	1	02	01	H4847_001_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H4847	005	0	1	02	01	H4847_005_0	4	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H4847	006	0	1	02	01	H4847_006_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	Once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	Every 6 months to 2 years	1	20	20	20	2				1	2	2	2	1	6	Every year to 5 years	1	20	20	20	2				1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	1	20	20	20	2				1	2																2	2	1	6	Every date of service to every 5 years	1	20	20	20	2				1	2
H4847	007	0	1	02	01	H4847_007_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H4869	001	0	1	02	01	H4869_001_0	7	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	6	1 upper and 1 lower denture per 5 years	1	20	20	20	2				1	2																																														2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H4869	003	0	1	02	01	H4869_003_0	6	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	1 upper, 1 lower denture per 5 years	1	20	20	20	2				1	2																																														2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H4869	011	0	1	02	01	H4869_011_0	7	2				2				2				2		2	2	1		1000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																																																													2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H4869	013	0	1	02	01	H4869_013_0	6	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	1 upper, 1 lower denture per 5 years	1	20	20	20	2				1	2																																														2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H4869	014	0	1	02	01	H4869_014_0	5	2				1	20	20	20	2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																																																													2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H4869	015	0	1	02	01	H4869_015_0	5	2				2				1	15.00	15.00	15.00	2		2	2																																																																																																																																																																																																																																																																																						
H4875	016	1	1	04	01	H4875_016_1	3	2				2				3		0.00	225.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	016	2	1	04	01	H4875_016_2	3	2				2				3		0.00	225.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	016	3	1	04	01	H4875_016_3	3	2				2				3		0.00	225.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	016	4	1	04	01	H4875_016_4	3	2				2				3		0.00	225.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	016	5	1	04	01	H4875_016_5	3	2				2				3		0.00	225.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	018	1	1	04	01	H4875_018_1	3	2				2				3		0.00	375.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	018	2	1	04	01	H4875_018_2	3	2				2				3		0.00	375.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	018	5	1	04	01	H4875_018_5	3	2				2				3		0.00	375.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	020	1	1	04	01	H4875_020_1	3	2				2				3		0.00	425.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	020	2	1	04	01	H4875_020_2	3	2				2				3		0.00	425.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	020	3	1	04	01	H4875_020_3	3	2				2				3		0.00	425.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	024	1	1	04	01	H4875_024_1	3	2				2				3		0.00	450.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	024	2	1	04	01	H4875_024_2	3	2				2				3		0.00	450.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	024	5	1	04	01	H4875_024_5	4	2				2				3		0.00	450.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	803	0	1	04	01	H4875_803_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4875	804	0	1	04	01	H4875_804_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4875	805	0	1	04	01	H4875_805_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4875	806	0	1	04	01	H4875_806_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4875	807	0	1	04	01	H4875_807_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4875	810	0	1	04	01	H4875_810_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4882	015	0	1	04	01	H4882_015_0	6	2				2				2				2		2	2	2							2				2					2					2		4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2	4	2	1	1		2				2				2	2	2								2					2		3													2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H4882	016	0	1	04	01	H4882_016_0	5	2				2				2				2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2	4	2	1	1		2				2				2	2	2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H4882	017	0	1	04	01	H4882_017_0	5	2				2				2				2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2	4	2	1	1		2				2				2	2	2								2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H4882	018	0	1	04	01	H4882_018_0	6	2				2				2				2		2	2	2							2				2					2					2		4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2	4	2	1	1		2				2				2	2	2								2					2		3													2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H4882	801	0	1	04	01	H4882_801_0	1	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4882	803	0	1	04	01	H4882_803_0	1	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4882	804	0	1	04	01	H4882_804_0	1	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4882	805	0	1	04	01	H4882_805_0	1	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4882	806	0	1	04	01	H4882_806_0	1	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4909	014	0	1	04	01	H4909_014_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4909	020	0	1	04	01	H4909_020_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4909	021	0	1	04	01	H4909_021_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4909	023	0	1	04	01	H4909_023_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4909	026	0	1	04	01	H4909_026_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4909	029	0	1	04	01	H4909_029_0	5	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4909	030	0	1	04	01	H4909_030_0	5	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4909	804	0	1	04	01	H4909_804_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4909	805	0	1	04	01	H4909_805_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4909	810	0	2	04	01	H4909_810_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4909	811	0	1	04	01	H4909_811_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4909	812	0	1	04	01	H4909_812_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4909	814	0	2	04	01	H4909_814_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4909	815	0	2	04	01	H4909_815_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4909	817	0	1	04	01	H4909_817_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4909	818	0	1	04	01	H4909_818_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4919	001	0	1	20	08	H4919_001_0	1																																																																																																																																																																																																																																																																																																						
H4919	002	0	1	20	08	H4919_002_0	1																																																																																																																																																																																																																																																																																																						
H4931	007	0	1	01	01	H4931_007_0	5	2				1	20	20	20	2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	1 of 2 or 4 image or intraoral tomosynthesis bitewing per 12 mo1 intraoral comp series, tomosynthesis radiographic, panoramic per 36 mo1 intraoral tomosynthesis-periapical radiographic image per 12 mo	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Fillings-one per tooth per 36 monthsCrowns, post, core, pins-one per tooth per 60 monthsRecement/rebond crowns- after 6 months of initial placement	2				2				2	2	2	2	1	6	1 per tooth per lifetime for pulpotomy or root canals.	2				2				2	2	2	2	1	6	Osseous surgery-1 per 24 months per quadrantPeriodontal scaling and root planing-1 per 24 months per quadrantFull mouth debridement-1 per 36 monthsPeriodontal Maintenance-1 every 3 months	2				2				2	2	2	2	1	6	1 of Removable complete, partial or immediate dentures per 60 monthsAdjustments after 6 months of placementRebase and relines every 36 months after 6 months of placement	2				2				2	2																															2	2	1	6	Fixed dentures (bridges)-1 every 60 months per toothRecement fixed partial dentures after 6 months of placement	2				2				2	2	2	2	1	6	Extractions-1 per tooth per lifetime	2				2				2	2																2	1				2				2				2	2
H4931	015	0	1	01	01	H4931_015_0	5	2				1	20	20	20	2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	1 of 2 or 4 image or intraoral tomosynthesis bitewing per 12 mo1 intraoral comp series, tomosynthesis radiographic, panoramic per 36 mo1 intraoral tomosynthesis-periapical radiographic image per 12 mo	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Fillings-one per tooth per 36 monthsCrowns, post, core, pins-one per tooth per 60 monthsRecement/rebond crowns- after 6 months of initial placement	2				2				2	2	2	2	1	6	1 per tooth per lifetime for pulpotomy or root canals.	2				2				2	2	2	2	1	6	Osseous surgery-1 per 24 months per quadrantPeriodontal scaling and root planing-1 per 24 months per quadrantFull mouth debridement-1 per 36 monthsPeriodontal Maintenance-1 every 3 months	2				2				2	2	2	2	1	6	1 of Removable complete, partial or immediate dentures per 60 monthsAdjustments after 6 months of placementRebase and relines every 36 months after 6 months of placement	2				2				2	2																															2	2	1	6	Fixed dentures (bridges)-1 every 60 months per toothRecement fixed partial dentures after 6 months of placement	2				2				2	2	2	2	1	6	Extractions-1 per tooth per lifetime	2				2				2	2																2	1				2				2				2	2
H4937	801	0	1	04	01	H4937_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4937	802	0	1	04	01	H4937_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4937	803	0	1	04	01	H4937_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4937	804	0	1	04	01	H4937_804_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4937	805	0	1	04	01	H4937_805_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4937	806	0	2	04	01	H4937_806_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4937	807	0	2	04	01	H4937_807_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4937	808	0	1	04	01	H4937_808_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4937	809	0	1	04	01	H4937_809_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4937	810	0	1	04	01	H4937_810_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H4939	001	0	1	02	01	H4939_001_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	4	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam 1/yr, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/3 yrs, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	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	2				1	0.00	0.00	0.00	1	2
H4939	002	0	1	02	01	H4939_002_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4939	003	0	1	02	01	H4939_003_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4939	004	0	1	02	01	H4939_004_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	4	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam 1/yr, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/3 yrs, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	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	2				1	0.00	0.00	0.00	1	2
H4961	001	0	1	04	01	H4961_001_0	11	2				2				2				2		1	1	2							2				2					2					2		4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2																4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2																																																																																																																																																																																				
H4961	006	0	1	04	01	H4961_006_0	10	2				2				2				2		1	2	2							2				2					2					2		4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2																4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2																																																																																																																																																																																				
H4961	801	0	1	04	01	H4961_801_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H4961	802	0	1	04	01	H4961_802_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H4961	803	0	1	04	01	H4961_803_0	4	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H4961	804	0	1	04	01	H4961_804_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H4982	001	0	1	01	01	H4982_001_0	3	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4982	002	0	1	01	01	H4982_002_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4982	003	0	1	01	01	H4982_003_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H4982	007	0	1	01	01	H4982_007_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4982	022	0	1	01	01	H4982_022_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4982	025	0	1	01	01	H4982_025_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4982	026	0	1	01	01	H4982_026_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4982	030	0	1	01	01	H4982_030_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4982	801	0	1	01	01	H4982_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H4999	001	0	1	20	08	H4999_001_0	4																																																																																																																																																																																																																																																																																																						
H4999	002	0	1	20	08	H4999_002_0	4																																																																																																																																																																																																																																																																																																						
H5007	001	0	1	20	08	H5007_001_0	1																																																																																																																																																																																																																																																																																																						
H5007	002	0	1	20	08	H5007_002_0	1																																																																																																																																																																																																																																																																																																						
H5008	002	0	1	02	01	H5008_002_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5008	010	0	1	02	01	H5008_010_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5008	011	0	1	02	01	H5008_011_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5008	015	0	1	02	01	H5008_015_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5008	016	0	1	02	01	H5008_016_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5008	017	0	1	02	01	H5008_017_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5008	018	0	1	02	01	H5008_018_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5008	019	0	1	02	01	H5008_019_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5008	020	0	1	02	01	H5008_020_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5009	002	0	1	04	01	H5009_002_0	9	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H5009	801	0	1	04	01	H5009_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5009	802	0	1	04	01	H5009_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5015	001	0	1	01	01	H5015_001_0	6	2				1	20	20	20	2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5015	002	0	1	01	01	H5015_002_0	5	2				1	20	20	20	2				2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5037	001	0	1	20	08	H5037_001_0	1																																																																																																																																																																																																																																																																																																						
H5037	002	0	1	20	08	H5037_002_0	1																																																																																																																																																																																																																																																																																																						
H5042	801	0	1	04	01	H5042_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5042	802	0	1	04	01	H5042_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5042	803	0	1	04	01	H5042_803_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5042	805	0	1	04	01	H5042_805_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5042	806	0	1	04	01	H5042_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5042	807	0	1	04	01	H5042_807_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5042	808	0	1	04	01	H5042_808_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5042	809	0	1	04	01	H5042_809_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5042	810	0	1	04	01	H5042_810_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5042	811	0	1	04	01	H5042_811_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5042	812	0	1	04	01	H5042_812_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5050	001	0	1	01	01	H5050_001_0	7	2				2				1	30.00	30.00	30.00	2		1	1	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Bitewings 2 per yr; single bitewings not subject to frequency limits. Panoramic and full mouth series 1 per 3 yrs.	2				1	0.00	0.00	0.00	2	2	3													2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	2								2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	004	0	1	01	01	H5050_004_0	8	2				2				1	0.00	0.00	0.00	2		1	1	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Bitewings 2 per yr; single bitewings not subject to frequency limits. Panoramic and full mouth series 1 per 3 yrs.	2				1	0.00	0.00	0.00	2	2	3													2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	2								2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	009	0	1	01	01	H5050_009_0	8	2				2				1	25.00	25.00	25.00	2		1	1	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Bitewings 2 per yr; single bitewings not subject to frequency limits. Panoramic and full mouth series 1 per 3 yrs.	2				1	0.00	0.00	0.00	2	2	3													2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	2								2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	019	0	1	01	01	H5050_019_0	8	2				2				1	20.00	20.00	20.00	2		1	1	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Bitewings 2 per yr; single bitewings not subject to frequency limits. Panoramic and full mouth series 1 per 3 yrs.	2				1	0.00	0.00	0.00	2	2	3													2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	2								2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	021	0	1	01	01	H5050_021_0	8	2				2				1	50.00	50.00	50.00	2		1	1	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Bitewings 2 per yr; single bitewings not subject to frequency limits. Panoramic and full mouth series 1 per 3 yrs.	2				1	0.00	0.00	0.00	2	2	3													2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	2								2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	024	0	1	01	01	H5050_024_0	8	2				2				1	35.00	35.00	35.00	2		1	1	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Bitewings 2 per yr; single bitewings not subject to frequency limits. Panoramic and full mouth series 1 per 3 yrs.	2				1	0.00	0.00	0.00	2	2	3													2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	2								2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	025	0	1	01	01	H5050_025_0	8	2				2				1	35.00	35.00	35.00	2		1	1	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Bitewings 2 per yr; single bitewings not subject to frequency limits. Panoramic and full mouth series 1 per 3 yrs.	2				1	0.00	0.00	0.00	2	2	3													2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	2								2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	026	0	1	01	01	H5050_026_0	8	2				2				1	35.00	35.00	35.00	2		1	1	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Bitewings 2 per yr; single bitewings not subject to frequency limits. Panoramic and full mouth series 1 per 3 yrs.	2				1	0.00	0.00	0.00	2	2	3													2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	2								2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	027	0	1	01	01	H5050_027_0	8	2				2				1	35.00	35.00	35.00	2		1	1	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Bitewings 2 per yr; single bitewings not subject to frequency limits. Panoramic and full mouth series 1 per 3 yrs.	2				1	0.00	0.00	0.00	2	2	3													2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	2								2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	028	0	1	01	01	H5050_028_0	8	2				2				1	60.00	60.00	60.00	2		1	1																																																																																																																																																																																																																																																																																						
H5050	029	0	1	01	01	H5050_029_0	8	2				2				1	60.00	60.00	60.00	2		1	1																																																																																																																																																																																																																																																																																						
H5050	030	0	1	01	01	H5050_030_0	8	2				2				1	60.00	60.00	60.00	2		1	1																																																																																																																																																																																																																																																																																						
H5050	031	0	1	01	01	H5050_031_0	8	2				2				1	60.00	60.00	60.00	2		1	1																																																																																																																																																																																																																																																																																						
H5050	032	0	1	01	01	H5050_032_0	8	2				2				1	50.00	50.00	50.00	2		1	1																																																																																																																																																																																																																																																																																						
H5050	801	0	1	01	01	H5050_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5050	802	0	1	01	01	H5050_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5080	001	0	1	20	08	H5080_001_0	5																																																																																																																																																																																																																																																																																																						
H5080	002	0	1	20	08	H5080_002_0	5																																																																																																																																																																																																																																																																																																						
H5085	003	0	1	20	08	H5085_003_0	1																																																																																																																																																																																																																																																																																																						
H5085	004	0	1	20	08	H5085_004_0	1																																																																																																																																																																																																																																																																																																						
H5087	005	0	1	01	01	H5087_005_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	2	6	Every year to every 3 plan years	2				1	10.00	10.00	10.00	1	2	2	2	1	6	Every date of service to 3 years	2				3		0.00	20.00	1	2	2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	10.00	10.00	10.00	1	2	2	2	1	3		2				1	10.00	10.00	10.00	1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	540.00	1	2	2	1				2				3		35.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		35.00	250.00	1	2																2	1				2				3		0.00	150.00	1	2
H5087	035	0	1	01	01	H5087_035_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	6	Every year to every 3 plan years	2				1	10.00	10.00	10.00	1	2	2	2	1	6	Every date of service to 3 years	2				3		0.00	20.00	1	2	2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	10.00	10.00	10.00	1	2	2	2	1	3		2				1	10.00	10.00	10.00	1	2																2								2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	540.00	1	2	2	1				2				3		35.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		35.00	250.00	1	2																2	1				2				3		0.00	150.00	1	2
H5106	029	1	1	04	01	H5106_029_1	9	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		1	25	25	25	2				2	2
H5106	029	2	1	04	01	H5106_029_2	9	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		1	25	25	25	2				2	2
H5106	029	3	1	04	01	H5106_029_3	9	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		1	25	25	25	2				2	2
H5106	030	1	1	04	01	H5106_030_1	10	2				2				1	45.00	45.00	45.00	2		2	2	1	2	750.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H5106	030	2	1	04	01	H5106_030_2	10	2				2				1	45.00	45.00	45.00	2		2	2	1	2	750.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H5106	030	3	1	04	01	H5106_030_3	9	2				2				1	50.00	50.00	50.00	2		2	2	1	2	750.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H5106	034	1	1	04	01	H5106_034_1	9	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H5106	034	2	1	04	01	H5106_034_2	9	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H5106	038	0	1	04	01	H5106_038_0	6	2				2				1	10.00	10.00	10.00	2		2	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H5106	806	0	1	04	01	H5106_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5106	807	0	1	04	01	H5106_807_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5106	808	0	1	04	01	H5106_808_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5106	810	0	1	04	01	H5106_810_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5117	801	0	1	01	01	H5117_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5119	001	0	1	01	01	H5119_001_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5124	001	0	1	20	08	H5124_001_0	1																																																																																																																																																																																																																																																																																																						
H5124	002	0	1	20	08	H5124_002_0	1																																																																																																																																																																																																																																																																																																						
H5141	004	0	1	04	01	H5141_004_0	8	2				2				1	15.00	15.00	15.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	007	0	1	04	01	H5141_007_0	8	2				2				1	2.00	2.00	2.00	2		2	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	025	0	1	04	01	H5141_025_0	8	2				2				2				2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	026	0	1	04	01	H5141_026_0	8	2				2				1	15.00	15.00	15.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	032	0	1	04	01	H5141_032_0	8	2				2				1	20.00	20.00	20.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	036	0	1	04	01	H5141_036_0	8	2				2				1	15.00	15.00	15.00	2		2	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	038	0	1	04	01	H5141_038_0	8	2				2				1	5.00	5.00	5.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	042	0	1	04	01	H5141_042_0	8	2				2				1	5.00	5.00	5.00	2		2	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	045	0	1	04	01	H5141_045_0	8	2				2				1	5.00	5.00	5.00	2		2	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	054	0	1	04	01	H5141_054_0	8	2				2				1	50.00	50.00	50.00	2		2	2	1	2	500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	056	0	1	04	01	H5141_056_0	6	2				2				1	25.00	25.00	25.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	061	0	1	04	01	H5141_061_0	7	2				2				1	30.00	30.00	30.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	062	0	1	04	01	H5141_062_0	7	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	063	0	1	04	01	H5141_063_0	8	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																					
H5141	801	0	1	04	01	H5141_801_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5163	001	0	1	01	01	H5163_001_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2								2					2		2	2	2	3		2				3		0.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		25.00	1102.00	2	2																2	2	1	3		2				3		0.00	402.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		50.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H5163	002	0	1	01	01	H5163_002_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2								2					2		2	2	2	3		2				3		0.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		25.00	1102.00	2	2																2	2	1	3		2				3		0.00	402.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		50.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H5163	003	0	1	01	01	H5163_003_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2								2					2		2	2	2	3		2				3		0.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		25.00	1102.00	2	2																2	2	1	3		2				3		0.00	402.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		50.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H5163	004	0	1	01	01	H5163_004_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2								2					2		2	2	2	3		2				3		0.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		25.00	1102.00	2	2																2	2	1	3		2				3		0.00	402.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		50.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H5167	001	0	1	20	08	H5167_001_0	1																																																																																																																																																																																																																																																																																																						
H5167	002	0	1	20	08	H5167_002_0	1																																																																																																																																																																																																																																																																																																						
H5177	001	0	1	04	01	H5177_001_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5177	002	0	1	04	01	H5177_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5177	005	0	1	04	01	H5177_005_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5177	006	0	1	04	01	H5177_006_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5177	007	0	1	04	01	H5177_007_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5177	009	0	1	04	01	H5177_009_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5177	010	0	1	04	01	H5177_010_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5177	012	0	1	04	01	H5177_012_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5177	013	0	1	04	01	H5177_013_0	4	2				1	30	30	30	2				2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5177	014	0	1	04	01	H5177_014_0	4	2				1	30	30	30	2				2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5177	015	0	1	04	01	H5177_015_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5177	017	0	1	04	01	H5177_017_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5178	002	0	1	01	01	H5178_002_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5178	003	0	1	01	01	H5178_003_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5178	004	0	1	01	01	H5178_004_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5190	801	0	1	01	01	H5190_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5209	005	1	1	01	01	H5209_005_1	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		6000.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H5209	005	2	1	01	01	H5209_005_2	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		6000.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H5209	006	1	1	01	01	H5209_006_1	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H5209	006	2	1	01	01	H5209_006_2	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H5211	003	0	1	01	01	H5211_003_0	6	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																																																																																																																																																																																				
H5211	004	0	1	02	01	H5211_004_0	8	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																																																																																																																																																																																				
H5211	012	0	1	01	01	H5211_012_0	8	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																																																																																																																																																																																				
H5211	014	0	1	02	01	H5211_014_0	8	2				2				1	45.00	45.00	45.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																1	2		500.00	3		2		2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2
H5211	015	0	1	02	01	H5211_015_0	8	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																1	2		500.00	3		2		2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2
H5212	001	0	1	20	08	H5212_001_0	2																																																																																																																																																																																																																																																																																																						
H5212	002	0	1	20	08	H5212_002_0	2																																																																																																																																																																																																																																																																																																						
H5213	001	0	1	20	08	H5213_001_0	1																																																																																																																																																																																																																																																																																																						
H5213	002	0	1	20	08	H5213_002_0	1																																																																																																																																																																																																																																																																																																						
H5215	002	0	1	04	01	H5215_002_0	5	2				2				1	25.00	25.00	25.00	2		2	2	1	2	750.00	3		2		2				2					2	000000				2		4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2	1	1							2					2		4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2	3													2	2	4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2																4	1				1	50	50	50	2				1	2
H5215	005	0	1	04	01	H5215_005_0	5	2				2				1	0.00	0.00	0.00	2		2	2	1	2	100.00	3		2		2				2					1	100110	30.00	30.00	30.00	2		4	2	1	3		2								2	2	3													2	2	3													2	2	4	2	1	3		2								2	2	4	2	1	3		2								2	2	3													2	2																																																																																																																																																																					
H5215	007	0	1	04	01	H5215_007_0	6	2				1	20	20	20	2				2		2	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	3		2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5215	008	0	1	04	01	H5215_008_0	5	2				2				1	60.00	60.00	60.00	2		2	2	1	2	400.00	3		1	1	2				2					2	000000				2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	2	1				2				2				2	2	4	1				2				2				2	2
H5215	009	0	1	04	01	H5215_009_0	5	2				2				1	50.00	50.00	50.00	2		2	2	1	2	750.00	3		1	1	2				2					2	000000				2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	2	1				2				2				2	2	4	1				2				2				2	2
H5215	010	0	1	04	01	H5215_010_0	5	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1500.00	3		2		2				2					2	000000				2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				1	50	50	50	2				1	2
H5215	011	0	1	04	01	H5215_011_0	5	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1000.00	3		2		2				2					2	000000				2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				1	50	50	50	2				1	2
H5215	013	0	1	04	01	H5215_013_0	4	2				2				1	40.00	40.00	40.00	2		2	2	1	2	3500.00	3		2		2				2					2	000000				2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5215	014	0	1	04	01	H5215_014_0	4	2				2				1	40.00	40.00	40.00	2		2	2	1	2	3500.00	3		2		2				2					2	000000				2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5215	806	0	1	04	01	H5215_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	807	0	1	04	01	H5215_807_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	808	0	1	04	01	H5215_808_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	809	0	1	04	01	H5215_809_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	810	0	1	04	01	H5215_810_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	811	0	1	04	01	H5215_811_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	812	0	1	04	01	H5215_812_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	813	0	1	04	01	H5215_813_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	814	0	1	04	01	H5215_814_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	815	0	1	04	01	H5215_815_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	816	0	1	04	01	H5215_816_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	817	0	1	04	01	H5215_817_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	818	0	1	04	01	H5215_818_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	819	0	1	04	01	H5215_819_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	820	0	1	04	01	H5215_820_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	821	0	1	04	01	H5215_821_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	822	0	1	04	01	H5215_822_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	823	0	1	04	01	H5215_823_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	824	0	1	04	01	H5215_824_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	825	0	1	04	01	H5215_825_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5215	826	0	1	04	01	H5215_826_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	001	0	1	04	01	H5216_001_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	006	0	1	04	01	H5216_006_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	011	0	1	04	01	H5216_011_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	013	0	1	04	01	H5216_013_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	750.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	014	0	1	04	01	H5216_014_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	017	0	1	04	01	H5216_017_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	019	0	1	04	01	H5216_019_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	750.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	023	0	1	04	01	H5216_023_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	027	0	1	04	01	H5216_027_0	6	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	032	0	1	04	01	H5216_032_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	034	0	1	04	01	H5216_034_0	4	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	037	0	1	04	01	H5216_037_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	039	0	1	04	01	H5216_039_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	042	0	1	04	01	H5216_042_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	043	1	1	04	01	H5216_043_1	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	043	5	1	04	01	H5216_043_5	7	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	043	6	1	04	01	H5216_043_6	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	048	0	1	04	01	H5216_048_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	053	0	1	04	01	H5216_053_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	059	0	1	04	01	H5216_059_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	062	0	1	04	01	H5216_062_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	064	0	1	04	01	H5216_064_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	068	0	1	04	01	H5216_068_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	070	0	1	04	01	H5216_070_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	072	0	1	04	01	H5216_072_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	074	0	1	04	01	H5216_074_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	extractions 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	078	1	1	04	01	H5216_078_1	4	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	078	2	1	04	01	H5216_078_2	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	4000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	078	6	1	04	01	H5216_078_6	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	081	0	1	04	01	H5216_081_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	083	0	1	04	01	H5216_083_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	089	0	1	04	01	H5216_089_0	6	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	097	0	1	04	01	H5216_097_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	100	0	1	04	01	H5216_100_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	106	0	1	04	01	H5216_106_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	116	0	1	04	01	H5216_116_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	120	0	1	04	01	H5216_120_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	124	0	1	04	01	H5216_124_0	4	2				2				1	60.00	60.00	60.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	132	0	1	04	01	H5216_132_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	136	0	1	04	01	H5216_136_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	138	0	1	04	01	H5216_138_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	141	0	1	04	01	H5216_141_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	144	0	1	04	01	H5216_144_0	6	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	152	0	1	04	01	H5216_152_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	154	0	1	04	01	H5216_154_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	157	0	1	04	01	H5216_157_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	160	0	1	04	01	H5216_160_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	161	0	1	04	01	H5216_161_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	164	0	1	04	01	H5216_164_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	168	0	1	04	01	H5216_168_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	173	0	1	04	01	H5216_173_0	4	2				1	20	20	20	2				2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	174	0	1	04	01	H5216_174_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	175	0	1	04	01	H5216_175_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	179	0	1	04	01	H5216_179_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	180	0	1	04	01	H5216_180_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	188	0	1	04	01	H5216_188_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	190	0	1	04	01	H5216_190_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	192	0	1	04	01	H5216_192_0	4	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	194	0	1	04	01	H5216_194_0	6	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	200	0	1	04	01	H5216_200_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	201	0	1	04	01	H5216_201_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	203	1	1	04	01	H5216_203_1	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	203	2	1	04	01	H5216_203_2	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	205	0	1	04	01	H5216_205_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	0.00	0.00	0.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	206	0	1	04	01	H5216_206_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	207	0	1	04	01	H5216_207_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	211	0	1	04	01	H5216_211_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	216	0	1	04	01	H5216_216_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	217	0	1	04	01	H5216_217_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	218	0	1	04	01	H5216_218_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	219	0	1	04	01	H5216_219_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	220	0	1	04	01	H5216_220_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	221	0	1	04	01	H5216_221_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	223	0	1	04	01	H5216_223_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	224	0	1	04	01	H5216_224_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	225	0	1	04	01	H5216_225_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	226	0	1	04	01	H5216_226_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	227	0	1	04	01	H5216_227_0	4	2				1	20	20	20	2				2		1	2	1	2	750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	0.00	0.00	0.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	228	0	1	04	01	H5216_228_0	4	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	229	0	1	04	01	H5216_229_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	231	0	1	04	01	H5216_231_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	234	0	1	04	01	H5216_234_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	235	0	1	04	01	H5216_235_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	236	0	1	04	01	H5216_236_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	242	0	1	04	01	H5216_242_0	5	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	243	0	1	04	01	H5216_243_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	244	0	1	04	01	H5216_244_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	246	0	1	04	01	H5216_246_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	249	0	1	04	01	H5216_249_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	251	0	1	04	01	H5216_251_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	252	0	1	04	01	H5216_252_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	253	0	1	04	01	H5216_253_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	256	0	1	04	01	H5216_256_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	257	0	1	04	01	H5216_257_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	261	0	1	04	01	H5216_261_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1	2	5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	263	0	1	04	01	H5216_263_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	264	0	1	04	01	H5216_264_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	265	0	1	04	01	H5216_265_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	266	0	1	04	01	H5216_266_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	267	0	1	04	01	H5216_267_0	4	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	268	0	1	04	01	H5216_268_0	4	2				1	20	20	20	2				2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	269	0	1	04	01	H5216_269_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	271	0	1	04	01	H5216_271_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	277	0	1	04	01	H5216_277_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	278	1	1	04	01	H5216_278_1	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	278	3	1	04	01	H5216_278_3	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	280	1	1	04	01	H5216_280_1	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	280	2	1	04	01	H5216_280_2	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1250.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	281	0	1	04	01	H5216_281_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	283	0	1	04	01	H5216_283_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	284	0	1	04	01	H5216_284_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	285	0	1	04	01	H5216_285_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	286	0	1	04	01	H5216_286_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	288	0	1	04	01	H5216_288_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	289	0	1	04	01	H5216_289_0	6	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	291	0	1	04	01	H5216_291_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	292	0	1	04	01	H5216_292_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	296	0	1	04	01	H5216_296_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	298	0	1	04	01	H5216_298_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	300	0	1	04	01	H5216_300_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	302	0	1	04	01	H5216_302_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	306	0	1	04	01	H5216_306_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	3	2		2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	308	0	1	04	01	H5216_308_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	310	0	1	04	01	H5216_310_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	311	0	1	04	01	H5216_311_0	6	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2																																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	313	0	1	04	01	H5216_313_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	314	0	1	04	01	H5216_314_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	316	1	1	04	01	H5216_316_1	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	316	3	1	04	01	H5216_316_3	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	317	0	1	04	01	H5216_317_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	318	1	1	04	01	H5216_318_1	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	318	2	1	04	01	H5216_318_2	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	318	3	1	04	01	H5216_318_3	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	319	0	1	04	01	H5216_319_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	322	0	1	04	01	H5216_322_0	7	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	325	0	1	04	01	H5216_325_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	326	0	1	04	01	H5216_326_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	327	0	1	04	01	H5216_327_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	750.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	3	2		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				3		0.00	25.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	328	0	1	04	01	H5216_328_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	3	2		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				3		0.00	25.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	330	0	1	04	01	H5216_330_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	0.00	0.00	0.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	331	0	1	04	01	H5216_331_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	332	0	1	04	01	H5216_332_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	0.00	0.00	0.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	334	0	1	04	01	H5216_334_0	6	2				2				1	5.00	5.00	5.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	337	1	1	04	01	H5216_337_1	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	337	2	1	04	01	H5216_337_2	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	337	3	1	04	01	H5216_337_3	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	339	0	1	04	01	H5216_339_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	340	0	1	04	01	H5216_340_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	343	0	1	04	01	H5216_343_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	345	0	1	04	01	H5216_345_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	347	0	1	04	01	H5216_347_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	348	0	1	04	01	H5216_348_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	350	0	1	04	01	H5216_350_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	351	0	1	04	01	H5216_351_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	352	0	1	04	01	H5216_352_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	355	0	1	04	01	H5216_355_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	358	0	1	04	01	H5216_358_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	361	0	1	04	01	H5216_361_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	362	0	1	04	01	H5216_362_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	363	0	1	04	01	H5216_363_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	366	0	1	04	01	H5216_366_0	6	2				2				1	15.00	15.00	15.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	367	0	1	04	01	H5216_367_0	4	2				1	20	20	20	2				2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	368	0	1	04	01	H5216_368_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	369	0	1	04	01	H5216_369_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	370	0	1	04	01	H5216_370_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	371	0	1	04	01	H5216_371_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	372	0	1	04	01	H5216_372_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	375	0	1	04	01	H5216_375_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	376	0	1	04	01	H5216_376_0	4	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	379	0	1	04	01	H5216_379_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	381	0	1	04	01	H5216_381_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	382	0	1	04	01	H5216_382_0	4	2				1	20	20	20	2				2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	383	0	1	04	01	H5216_383_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	384	0	1	04	01	H5216_384_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	385	0	1	04	01	H5216_385_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	387	1	1	04	01	H5216_387_1	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	387	2	1	04	01	H5216_387_2	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	388	0	1	04	01	H5216_388_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	390	0	1	04	01	H5216_390_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	394	0	1	04	01	H5216_394_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	399	0	1	04	01	H5216_399_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	401	0	1	04	01	H5216_401_0	5	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	403	0	1	04	01	H5216_403_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	404	0	1	04	01	H5216_404_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	405	0	1	04	01	H5216_405_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	406	0	1	04	01	H5216_406_0	5	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	407	0	1	04	01	H5216_407_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	408	0	1	04	01	H5216_408_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	409	0	1	04	01	H5216_409_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	410	0	1	04	01	H5216_410_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	416	0	1	04	01	H5216_416_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	417	0	1	04	01	H5216_417_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	420	0	1	04	01	H5216_420_0	4	2				1	20	20	20	2				2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	421	0	1	04	01	H5216_421_0	5	2				2				1	60.00	60.00	60.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	423	0	1	04	01	H5216_423_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	425	0	1	04	01	H5216_425_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	427	1	1	04	01	H5216_427_1	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	427	2	1	04	01	H5216_427_2	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	427	3	1	04	01	H5216_427_3	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	427	4	1	04	01	H5216_427_4	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	427	5	1	04	01	H5216_427_5	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	428	1	1	04	01	H5216_428_1	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	428	2	1	04	01	H5216_428_2	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	428	3	1	04	01	H5216_428_3	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	428	5	1	04	01	H5216_428_5	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	430	0	1	04	01	H5216_430_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	431	0	1	04	01	H5216_431_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	432	0	1	04	01	H5216_432_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	433	0	1	04	01	H5216_433_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	435	1	1	04	01	H5216_435_1	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	750.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	435	2	1	04	01	H5216_435_2	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	435	3	1	04	01	H5216_435_3	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	436	1	1	04	01	H5216_436_1	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	436	2	1	04	01	H5216_436_2	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	436	3	1	04	01	H5216_436_3	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	441	0	1	04	01	H5216_441_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	442	0	1	04	01	H5216_442_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	443	0	1	04	01	H5216_443_0	4	2				1	20	20	20	2				2		1	2	1	2	750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	446	0	1	04	01	H5216_446_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	455	0	1	04	01	H5216_455_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	457	1	1	04	01	H5216_457_1	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	5000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	457	2	1	04	01	H5216_457_2	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	461	0	1	04	01	H5216_461_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	463	0	1	04	01	H5216_463_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	464	0	1	04	01	H5216_464_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	750.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	465	0	1	04	01	H5216_465_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	466	0	1	04	01	H5216_466_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	471	0	1	04	01	H5216_471_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	472	0	1	04	01	H5216_472_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	473	0	1	04	01	H5216_473_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5216	474	0	1	04	01	H5216_474_0	4	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	475	0	1	04	01	H5216_475_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5216	476	0	1	04	01	H5216_476_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	477	0	1	04	01	H5216_477_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	478	0	1	04	01	H5216_478_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	479	0	1	04	01	H5216_479_0	5	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	480	0	1	04	01	H5216_480_0	5	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	481	1	1	04	01	H5216_481_1	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3				2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	481	2	1	04	01	H5216_481_2	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3				2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5216	805	0	1	04	01	H5216_805_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	806	0	1	04	01	H5216_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	808	0	2	04	01	H5216_808_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	809	0	2	04	01	H5216_809_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	811	0	1	04	01	H5216_811_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	812	0	1	04	01	H5216_812_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	813	0	1	04	01	H5216_813_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	814	0	1	04	01	H5216_814_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	817	0	1	04	01	H5216_817_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	818	0	1	04	01	H5216_818_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	821	0	1	04	01	H5216_821_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5216	824	0	1	04	01	H5216_824_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5244	801	0	1	01	01	H5244_801_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5244	802	0	1	01	01	H5244_802_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5244	803	0	1	01	01	H5244_803_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5244	804	0	1	01	01	H5244_804_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5253	004	0	1	02	01	H5253_004_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	007	0	1	02	01	H5253_007_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	011	0	1	02	01	H5253_011_0	6	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	021	0	1	02	01	H5253_021_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	030	0	1	02	01	H5253_030_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	033	0	1	02	01	H5253_033_0	3	2				1	20	20	20	2				2		1	2	1		500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	034	0	1	02	01	H5253_034_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	035	0	1	02	01	H5253_035_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	036	0	1	02	01	H5253_036_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	037	0	1	02	01	H5253_037_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	038	0	1	02	01	H5253_038_0	5	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	039	0	1	02	01	H5253_039_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	040	0	1	02	01	H5253_040_0	2	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	047	0	1	02	01	H5253_047_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	048	0	1	02	01	H5253_048_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	051	0	1	02	01	H5253_051_0	6	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	062	0	1	02	01	H5253_062_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	064	0	1	02	01	H5253_064_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5253	072	0	1	02	01	H5253_072_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	080	0	1	02	01	H5253_080_0	6	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	081	0	1	02	01	H5253_081_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	082	0	1	02	01	H5253_082_0	5	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	084	0	1	02	01	H5253_084_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	087	0	1	02	01	H5253_087_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	088	0	1	02	01	H5253_088_0	5	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	089	0	1	02	01	H5253_089_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	099	0	1	02	01	H5253_099_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	100	0	1	02	01	H5253_100_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	103	0	1	02	01	H5253_103_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	104	0	1	02	01	H5253_104_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	105	0	1	02	01	H5253_105_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	108	1	1	02	01	H5253_108_1	6	2				1	20	20	20	2				2		1	2	1		1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	108	2	1	02	01	H5253_108_2	6	2				1	20	20	20	2				2		1	2	1		2000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	110	0	1	02	01	H5253_110_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	113	0	1	02	01	H5253_113_0	3	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	116	0	1	02	01	H5253_116_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	117	0	1	02	01	H5253_117_0	6	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	119	0	1	02	01	H5253_119_0	3	2				1	20	20	20	2				2		1	2																																																																																																																		2								2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H5253	121	0	1	02	01	H5253_121_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	124	1	1	02	01	H5253_124_1	6	2				1	20	20	20	2				2		1	2	1		1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	124	2	1	02	01	H5253_124_2	4	2				1	20	20	20	2				2		1	2	1		1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	125	1	1	02	01	H5253_125_1	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	125	2	1	02	01	H5253_125_2	6	2				1	20	20	20	2				2		1	2	1		1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	126	1	1	02	01	H5253_126_1	6	2				1	20	20	20	2				2		1	2	1		5000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	126	2	1	02	01	H5253_126_2	5	2				1	20	20	20	2				2		1	2	1		5000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	127	0	1	02	01	H5253_127_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	128	0	1	02	01	H5253_128_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	130	0	1	02	01	H5253_130_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	131	0	1	02	01	H5253_131_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	132	0	1	02	01	H5253_132_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	133	0	1	02	01	H5253_133_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	134	0	1	02	01	H5253_134_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	135	0	1	02	01	H5253_135_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	141	0	1	02	01	H5253_141_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	142	0	1	02	01	H5253_142_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	143	0	1	02	01	H5253_143_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	144	1	1	02	01	H5253_144_1	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	144	2	1	02	01	H5253_144_2	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	145	0	1	02	01	H5253_145_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	146	0	1	02	01	H5253_146_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	147	0	1	02	01	H5253_147_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	148	0	1	02	01	H5253_148_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	149	0	1	02	01	H5253_149_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	150	0	1	02	01	H5253_150_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	152	0	1	02	01	H5253_152_0	3	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	154	0	1	02	01	H5253_154_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	155	0	1	02	01	H5253_155_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	157	1	1	02	01	H5253_157_1	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	157	2	1	02	01	H5253_157_2	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	161	0	1	02	01	H5253_161_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	162	1	1	02	01	H5253_162_1	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	162	2	1	02	01	H5253_162_2	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	166	0	1	02	01	H5253_166_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5253	168	0	1	02	01	H5253_168_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	171	0	1	02	01	H5253_171_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	172	0	1	02	01	H5253_172_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	173	0	1	02	01	H5253_173_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	174	0	1	02	01	H5253_174_0	4	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	175	0	1	02	01	H5253_175_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	176	0	1	02	01	H5253_176_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	179	0	1	02	01	H5253_179_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	182	0	1	02	01	H5253_182_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	183	0	1	02	01	H5253_183_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	185	0	1	02	01	H5253_185_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	186	0	1	02	01	H5253_186_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	187	0	1	02	01	H5253_187_0	3	2				1	20	20	20	2				2		1	2	1		750.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	188	0	1	02	01	H5253_188_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	189	0	1	02	01	H5253_189_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	190	0	1	02	01	H5253_190_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	192	0	1	02	01	H5253_192_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	193	1	1	02	01	H5253_193_1	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	193	2	1	02	01	H5253_193_2	4	2				1	20	20	20	2				2		1	2	1		1250.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	194	1	1	02	01	H5253_194_1	4	2				1	20	20	20	2				2		1	2	1		2000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	194	2	1	02	01	H5253_194_2	4	2				1	20	20	20	2				2		1	2	1		3000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	195	0	1	02	01	H5253_195_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	196	0	1	02	01	H5253_196_0	4	2				1	20	20	20	2				2		1	2	1		2250.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	197	0	1	02	01	H5253_197_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	199	0	1	02	01	H5253_199_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	200	0	1	02	01	H5253_200_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5253	201	0	1	02	01	H5253_201_0	6	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	202	0	1	02	01	H5253_202_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	203	0	1	02	01	H5253_203_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	204	0	1	02	01	H5253_204_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	205	0	1	02	01	H5253_205_0	2	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	206	0	1	02	01	H5253_206_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	207	0	1	02	01	H5253_207_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	213	0	1	02	01	H5253_213_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	214	0	1	02	01	H5253_214_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	216	1	1	02	01	H5253_216_1	5	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5253	216	2	1	02	01	H5253_216_2	5	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5253	217	1	1	02	01	H5253_217_1	5	2				1	20	20	20	2				2		1	2	1		1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5253	217	2	1	02	01	H5253_217_2	5	2				1	20	20	20	2				2		1	2	1		1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5253	221	0	1	02	01	H5253_221_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	222	0	1	02	01	H5253_222_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	223	0	1	02	01	H5253_223_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	225	0	1	02	01	H5253_225_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	226	0	1	02	01	H5253_226_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	234	1	1	02	01	H5253_234_1	4	2				1	30	30	30	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5253	234	2	1	02	01	H5253_234_2	4	2				1	30	30	30	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5253	235	0	1	02	01	H5253_235_0	3	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	239	0	1	01	01	H5253_239_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	240	0	1	02	01	H5253_240_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	241	0	1	02	01	H5253_241_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	243	1	1	02	01	H5253_243_1	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	243	2	1	02	01	H5253_243_2	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	244	0	1	02	01	H5253_244_0	3	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	246	0	1	02	01	H5253_246_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	247	0	1	02	01	H5253_247_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	248	0	1	02	01	H5253_248_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	249	0	1	02	01	H5253_249_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	253	0	1	02	01	H5253_253_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5253	255	0	1	02	01	H5253_255_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	256	0	1	02	01	H5253_256_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	257	0	1	02	01	H5253_257_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	258	0	1	02	01	H5253_258_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	259	0	1	02	01	H5253_259_0	6	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	260	0	1	02	01	H5253_260_0	5	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5253	262	0	1	02	01	H5253_262_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5253	264	0	1	02	01	H5253_264_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5253	801	0	1	01	01	H5253_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	802	0	1	01	01	H5253_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	805	0	1	01	01	H5253_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	810	0	1	01	01	H5253_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	811	0	1	01	01	H5253_811_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	812	0	1	01	01	H5253_812_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	813	0	1	01	01	H5253_813_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	814	0	1	01	01	H5253_814_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	815	0	1	01	01	H5253_815_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	816	0	2	01	01	H5253_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	817	0	2	01	01	H5253_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	818	0	1	01	01	H5253_818_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	819	0	1	01	01	H5253_819_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	820	0	1	01	01	H5253_820_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	821	0	1	01	01	H5253_821_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	822	0	1	01	01	H5253_822_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	823	0	1	01	01	H5253_823_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	824	0	1	01	01	H5253_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	825	0	1	01	01	H5253_825_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	826	0	2	01	01	H5253_826_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	827	0	1	01	01	H5253_827_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	828	0	1	01	01	H5253_828_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	829	0	1	01	01	H5253_829_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	830	0	1	01	01	H5253_830_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	831	0	1	01	01	H5253_831_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5253	832	0	1	01	01	H5253_832_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5256	001	0	1	18	06	H5256_001_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5256	002	0	1	18	06	H5256_002_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5256	004	0	1	18	06	H5256_004_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5256	005	0	1	18	06	H5256_005_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5262	001	0	1	01	01	H5262_001_0	6	2				2				1	45.00	45.00	45.00	2		2	2	1		550.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	003	0	1	01	01	H5262_003_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1		375.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	004	0	1	01	01	H5262_004_0	4	2				2				1	50.00	50.00	50.00	2		2	2	1		1000.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	005	0	1	01	01	H5262_005_0	4	2				2				1	45.00	45.00	45.00	2		2	2	1		1000.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	007	0	1	01	01	H5262_007_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1		525.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	008	0	1	01	01	H5262_008_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1		425.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	009	0	1	01	01	H5262_009_0	4	2				2				1	40.00	40.00	40.00	2		2	2	1		1750.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	010	0	1	01	01	H5262_010_0	4	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	021	0	1	01	01	H5262_021_0	6	2				2				1	60.00	60.00	60.00	2		2	2	1		350.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	023	0	1	01	01	H5262_023_0	6	2				2				1	65.00	65.00	65.00	2		2	2	1		300.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	029	0	1	01	01	H5262_029_0	6	2				1	20	20	20	2				2		2	2	1		2500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5262	030	0	1	01	01	H5262_030_0	6	2				1	20	20	20	2				2		2	2	1		2500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5262	032	0	1	01	01	H5262_032_0	6	2				2				1	75.00	75.00	75.00	2		2	2	2							2				2					2					2		4	2	1	2		2				2				2	2	3													2	2	3													2	2	4	2	1	2		2				2				2	2	3													2	2																																																																																																																																																																																				
H5262	033	0	1	01	01	H5262_033_0	6	2				2				1	75.00	75.00	75.00	2		2	2	2							2				2					2					2		4	2	1	2		2				2				2	2	3													2	2	3													2	2	4	2	1	2		2				2				2	2	3													2	2																																																																																																																																																																																				
H5262	801	0	1	01	01	H5262_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5262	802	0	1	01	01	H5262_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5264	002	0	1	18	06	H5264_002_0	2	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H5264	005	0	1	18	06	H5264_005_0	3	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	3		2				2				2	2																																																																																																																																																																					
H5272	001	0	1	01	01	H5272_001_0	7	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5294	010	0	1	01	01	H5294_010_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5294	014	0	1	01	01	H5294_014_0	2	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5294	017	0	1	01	01	H5294_017_0	5	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	Once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	Every 6 months to 2 years	1	40	40	40	2				1	2																																																													2	2	1	6	Per tooth per lifetime	1	40	40	40	2				1	2																2	2	1	6	Every date of service to every 5 years	1	40	40	40	2				1	2
H5294	018	0	1	01	01	H5294_018_0	5	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5294	021	0	1	01	01	H5294_021_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5294	022	0	1	01	01	H5294_022_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5294	023	0	1	01	01	H5294_023_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5294	024	0	1	01	01	H5294_024_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5294	025	0	1	01	01	H5294_025_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5294	026	0	1	01	01	H5294_026_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H5296	004	0	1	02	01	H5296_004_0	9	2				2				2				2		1	2	1		2400.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	006	0	1	01	01	H5296_006_0	9	2				2				2				2		1	2	2							2				2					2					2		4	1				2				1	10.00	10.00	10.00	1	1	4	1				2				1	30.00	30.00	30.00	1	1																4	1				2				1	20.00	20.00	20.00	1	1	4	1				2				1	10.00	10.00	10.00	1	1																																																																																																																																																																																				
H5296	007	0	1	01	01	H5296_007_0	9	2				2				2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	008	0	1	01	01	H5296_008_0	11	2				2				2				2		1	2	2							2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																															3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																														
H5296	009	0	1	02	01	H5296_009_0	9	2				2				2				2		1	2	1		2400.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	010	0	1	01	01	H5296_010_0	11	2				2				2				2		1	2	2							2				2					2					2		2	1				2				1	10.00	10.00	10.00	1	2	2	1				2				1	30.00	30.00	30.00	1	2																2	1				2				1	20.00	20.00	20.00	1	2	2	1				2				1	10.00	10.00	10.00	1	2																1	2		2000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	011	0	1	01	01	H5296_011_0	10	2				2				2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	012	0	1	01	01	H5296_012_0	9	2				2				2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	013	0	1	01	01	H5296_013_0	8	2				2				2				2		1	2	2							2				2					2					2		4	2	1	4		2				2				1	1	4	2	1	1		2				2				1	1																4	2	1	4		2				2				1	1	4	2	1	4		2				2				1	1																																																																																																																																																																																				
H5296	801	0	1	01	01	H5296_801_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5296	802	0	1	01	01	H5296_802_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5296	803	0	1	01	01	H5296_803_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5296	804	0	1	01	01	H5296_804_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5299	001	0	1	01	01	H5299_001_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	002	0	1	01	01	H5299_002_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5299	006	0	1	01	01	H5299_006_0	4	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	009	0	1	01	01	H5299_009_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	012	0	1	01	01	H5299_012_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5299	013	0	1	01	01	H5299_013_0	4	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	014	0	1	01	01	H5299_014_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	015	0	1	01	01	H5299_015_0	4	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	016	0	1	01	01	H5299_016_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	017	0	1	01	01	H5299_017_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	018	0	1	01	01	H5299_018_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	021	0	1	01	01	H5299_021_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	022	0	1	01	01	H5299_022_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5299	023	0	1	01	01	H5299_023_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	024	0	1	01	01	H5299_024_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5299	029	0	1	01	01	H5299_029_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	030	0	1	01	01	H5299_030_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5299	031	0	1	01	01	H5299_031_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	032	0	1	01	01	H5299_032_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	033	0	1	01	01	H5299_033_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	034	0	1	01	01	H5299_034_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	037	0	1	01	01	H5299_037_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	038	0	1	01	01	H5299_038_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	039	0	1	01	01	H5299_039_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	041	0	1	01	01	H5299_041_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	042	0	1	01	01	H5299_042_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	044	0	1	01	01	H5299_044_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5299	045	0	1	01	01	H5299_045_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5302	012	0	1	01	01	H5302_012_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5302	020	0	1	01	01	H5302_020_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		1200.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5302	022	0	1	01	01	H5302_022_0	3	2				2				1	59.00	59.00	59.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5302	024	0	1	01	01	H5302_024_0	3	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5302	026	0	1	01	01	H5302_026_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5302	028	0	1	01	01	H5302_028_0	3	2				2				1	39.00	39.00	39.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5302	809	0	1	01	01	H5302_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5314	001	0	1	01	01	H5314_001_0	6	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5314	002	0	1	01	01	H5314_002_0	6	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5322	025	0	1	02	01	H5322_025_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5322	033	0	1	02	01	H5322_033_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5322	038	0	1	02	01	H5322_038_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5322	040	0	1	02	01	H5322_040_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5322	043	0	1	02	01	H5322_043_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5322	044	0	1	02	01	H5322_044_0	7	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H5322	046	0	1	02	01	H5322_046_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5322	049	1	1	02	01	H5322_049_1	7	2				1	20	20	20	2				2		1	2	1		2000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5322	049	2	1	02	01	H5322_049_2	5	2				1	20	20	20	2				2		1	2	1		2000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5322	049	3	1	02	01	H5322_049_3	5	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5322	050	1	1	02	01	H5322_050_1	5	2				1	20	20	20	2				2		1	2	1		1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5322	050	2	1	02	01	H5322_050_2	5	2				1	20	20	20	2				2		1	2	1		1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5322	050	3	1	02	01	H5322_050_3	5	2				1	20	20	20	2				2		1	2	1		1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5322	052	1	1	02	01	H5322_052_1	5	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5322	052	2	1	02	01	H5322_052_2	5	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5322	052	3	1	02	01	H5322_052_3	5	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H5322	053	0	1	02	01	H5322_053_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5322	801	0	1	01	01	H5322_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5322	802	0	1	01	01	H5322_802_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5322	803	0	1	01	01	H5322_803_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5322	804	0	2	01	01	H5322_804_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5325	003	0	1	01	01	H5325_003_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	004	0	1	01	01	H5325_004_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	005	0	1	01	01	H5325_005_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	006	0	1	01	01	H5325_006_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	007	0	1	01	01	H5325_007_0	3	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	012	0	1	01	01	H5325_012_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	013	0	1	01	01	H5325_013_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	014	0	1	01	01	H5325_014_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	015	0	1	01	01	H5325_015_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5334	001	0	1	04	01	H5334_001_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5334	002	0	1	04	01	H5334_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5334	003	0	1	04	01	H5334_003_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5334	004	0	1	04	01	H5334_004_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5334	007	0	1	04	01	H5334_007_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5334	008	0	1	04	01	H5334_008_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5334	009	0	1	04	01	H5334_009_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5334	010	0	1	04	01	H5334_010_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5334	013	0	1	04	01	H5334_013_0	4	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5334	014	0	1	04	01	H5334_014_0	4	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5334	015	0	1	04	01	H5334_015_0	4	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5334	016	0	1	04	01	H5334_016_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5334	017	0	1	04	01	H5334_017_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5334	019	0	1	04	01	H5334_019_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5334	020	0	1	04	01	H5334_020_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5334	022	0	1	04	01	H5334_022_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5334	023	0	1	04	01	H5334_023_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5334	025	0	1	04	01	H5334_025_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5334	026	0	1	04	01	H5334_026_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5334	028	0	1	04	01	H5334_028_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5334	029	0	1	04	01	H5334_029_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5334	031	0	1	04	01	H5334_031_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5334	032	0	1	04	01	H5334_032_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5361	001	0	1	04	01	H5361_001_0	8	2				2				1	55.00	55.00	55.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H5374	001	0	1	01	01	H5374_001_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5377	002	0	1	02	01	H5377_002_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5377	003	0	1	01	01	H5377_003_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5380	001	0	1	20	08	H5380_001_0	1																																																																																																																																																																																																																																																																																																						
H5380	002	0	1	20	08	H5380_002_0	1																																																																																																																																																																																																																																																																																																						
H5384	001	0	1	20	08	H5384_001_0	1																																																																																																																																																																																																																																																																																																						
H5384	002	0	1	20	08	H5384_002_0	1																																																																																																																																																																																																																																																																																																						
H5386	801	0	1	01	01	H5386_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5386	802	0	1	01	01	H5386_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5386	803	0	1	01	01	H5386_803_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5397	001	0	1	01	01	H5397_001_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5397	002	0	1	01	01	H5397_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5397	003	0	1	01	01	H5397_003_0	5	2				1	30	30	30	2				2		1	2	1		2500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5397	004	0	1	01	01	H5397_004_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5397	005	0	1	01	01	H5397_005_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5397	006	0	1	01	01	H5397_006_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		2250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5397	007	0	1	01	01	H5397_007_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		2250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5397	008	0	1	01	01	H5397_008_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		1500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5397	009	0	1	01	01	H5397_009_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		1500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5403	001	0	1	20	08	H5403_001_0	1																																																																																																																																																																																																																																																																																																						
H5403	002	0	1	20	08	H5403_002_0	1																																																																																																																																																																																																																																																																																																						
H5405	001	0	1	20	08	H5405_001_0	2																																																																																																																																																																																																																																																																																																						
H5405	002	0	1	20	08	H5405_002_0	2																																																																																																																																																																																																																																																																																																						
H5406	001	0	1	20	08	H5406_001_0	1																																																																																																																																																																																																																																																																																																						
H5406	002	0	1	20	08	H5406_002_0	1																																																																																																																																																																																																																																																																																																						
H5410	004	0	1	01	01	H5410_004_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		800.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	013	0	1	01	01	H5410_013_0	5	2				2				1	5.00	5.00	5.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	018	0	1	01	01	H5410_018_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1700.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	024	0	1	01	01	H5410_024_0	6	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	025	0	1	01	01	H5410_025_0	5	2				2				2				2		1	2	1		2200.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	031	0	1	01	01	H5410_031_0	5	2				2				2				2		1	2	1		2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	032	0	1	01	01	H5410_032_0	5	2				2				2				2		1	2	1		1900.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	042	0	1	01	01	H5410_042_0	5	2				2				2				2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	045	0	1	01	01	H5410_045_0	5	2				1	20	20	20	2				2		1	2	1		1300.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	046	0	1	01	01	H5410_046_0	5	2				1	20	20	20	2				2		1	2	1		1800.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	059	0	1	01	01	H5410_059_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		1900.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	808	0	1	01	01	H5410_808_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5420	001	0	1	01	01	H5420_001_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	2	2																																														2	1				2				1	0.00	0.00	0.00	2	2																														
H5420	003	0	1	01	01	H5420_003_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	2	2																																														2	1				2				1	0.00	0.00	0.00	2	2																														
H5420	014	0	1	01	01	H5420_014_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	2	2																																														2	1				2				1	0.00	0.00	0.00	2	2																														
H5422	014	0	1	02	01	H5422_014_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1		1600.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5422	015	0	1	02	01	H5422_015_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5422	018	0	1	01	01	H5422_018_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1600.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5422	019	0	1	01	01	H5422_019_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5422	020	0	1	02	01	H5422_020_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H5422	803	0	1	01	01	H5422_803_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5422	804	0	1	01	01	H5422_804_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5422	806	0	2	01	01	H5422_806_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5422	807	0	2	01	01	H5422_807_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5422	809	0	1	01	01	H5422_809_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5422	811	0	2	01	01	H5422_811_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5425	001	0	1	01	01	H5425_001_0	10	2				2				2				2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	005	0	1	01	01	H5425_005_0	10	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	006	0	1	01	01	H5425_006_0	13	2				2				2				2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	007	0	1	01	01	H5425_007_0	11	2				2				2				2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	008	0	1	01	01	H5425_008_0	11	2				2				2				2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	009	0	1	01	01	H5425_009_0	11	2				2				2				2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	019	0	1	01	01	H5425_019_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	034	0	1	01	01	H5425_034_0	11	2				2				2				2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	065	0	1	01	01	H5425_065_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		4000.00	3		2		2					2		2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																															2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				1	50	50	50	2				1	2
H5425	069	0	1	01	01	H5425_069_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2500.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	070	0	1	01	01	H5425_070_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	075	0	1	01	01	H5425_075_0	11	2				2				2				2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	076	0	1	01	01	H5425_076_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	082	0	1	01	01	H5425_082_0	10	2				2				2				2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	084	0	1	01	01	H5425_084_0	10	2				2				1	5.00	5.00	5.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	2	1				2				3		0.00	5.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				3		0.00	80.00	2	2	2								2					2		2	1				2				3		8.00	395.00	1	1	2	1				2				3		5.00	395.00	1	1	2	1				2				3		0.00	380.00	1	1	2	1				2				3		13.00	395.00	1	1																															2	1				2				3		25.00	395.00	1	1	2	1				2				3		0.00	140.00	1	1																2	1				2				3		0.00	125.00	1	1
H5425	085	0	1	01	01	H5425_085_0	10	2				2				1	5.00	5.00	5.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	2	1				2				3		0.00	5.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				3		0.00	80.00	2	2	2								2					2		2	1				2				3		8.00	395.00	1	1	2	1				2				3		5.00	395.00	1	1	2	1				2				3		0.00	380.00	1	1	2	1				2				3		13.00	395.00	1	1																															2	1				2				3		25.00	395.00	1	1	2	1				2				3		0.00	140.00	1	1																2	1				2				3		0.00	125.00	1	1
H5425	086	0	1	01	01	H5425_086_0	10	2				2				2				2		1	1	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	087	0	1	01	01	H5425_087_0	10	2				2				2				2		1	1	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	091	0	1	02	01	H5425_091_0	10	2				2				2				2		1	1	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	097	0	1	01	01	H5425_097_0	10	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1500.00	4		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	098	0	1	01	01	H5425_098_0	10	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1500.00	4		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	100	0	1	01	01	H5425_100_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2500.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	101	0	1	01	01	H5425_101_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	102	0	1	01	01	H5425_102_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	104	0	1	01	01	H5425_104_0	10	2				2				2				2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	105	0	1	01	01	H5425_105_0	10	2				2				2				2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	106	0	1	01	01	H5425_106_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	118	0	1	01	01	H5425_118_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	123	0	1	01	01	H5425_123_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	124	0	1	01	01	H5425_124_0	10	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	125	0	1	01	01	H5425_125_0	10	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	126	0	1	01	01	H5425_126_0	10	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	127	0	1	01	01	H5425_127_0	10	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	128	0	1	01	01	H5425_128_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	129	0	1	01	01	H5425_129_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	131	0	1	01	01	H5425_131_0	10	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	132	0	1	02	01	H5425_132_0	11	2				1	20	20	20	2				2		1	1	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	133	0	1	01	01	H5425_133_0	10	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	2	1				2				3		0.00	5.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				3		0.00	80.00	2	2	2								2					2		2	1				2				3		8.00	395.00	1	1	2	1				2				3		5.00	395.00	1	1	2	1				2				3		0.00	380.00	1	1	2	1				2				3		13.00	395.00	1	1																															2	1				2				3		25.00	395.00	1	1	2	1				2				3		0.00	140.00	1	1																2	1				2				3		0.00	125.00	1	1
H5425	134	0	1	01	01	H5425_134_0	10	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	135	0	1	01	01	H5425_135_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		4000.00	3		2		2					2		2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																															2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				1	50	50	50	2				1	2
H5425	136	0	1	01	01	H5425_136_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H5425	137	0	1	01	01	H5425_137_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H5425	138	0	1	01	01	H5425_138_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																					
H5425	139	0	1	01	01	H5425_139_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1000.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H5425	140	0	1	01	01	H5425_140_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H5425	141	0	1	01	01	H5425_141_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H5425	142	0	1	01	01	H5425_142_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H5425	143	0	1	01	01	H5425_143_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H5425	144	0	1	01	01	H5425_144_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H5425	145	0	1	01	01	H5425_145_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H5425	146	0	1	01	01	H5425_146_0	10	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H5425	147	0	1	01	01	H5425_147_0	10	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	148	0	1	01	01	H5425_148_0	10	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	149	0	1	01	01	H5425_149_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	150	0	1	01	01	H5425_150_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	151	0	1	01	01	H5425_151_0	10	2				2				2				2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	152	0	1	01	01	H5425_152_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																															2	1				1	25	25	25	2				1	1	2	1				1	25	25	25	2				1	1																2	1				1	25	25	25	2				1	1
H5425	153	0	1	01	01	H5425_153_0	10	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5425	155	0	1	01	01	H5425_155_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1375.00	4		2		2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				2	2	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H5425	156	0	1	01	01	H5425_156_0	10	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1500.00	4		2		2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				2	2	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H5425	158	0	1	01	01	H5425_158_0	10	2				2				2				2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	159	0	1	01	01	H5425_159_0	10	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	6	Bitewings:  2 sets per 12 monthsComprehensive Series / Panoramic: 1 per 24 months	2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2								2					2		4	1				2				3		8.00	395.00	1	1	4	1				2				3		5.00	395.00	1	1	4	1				2				3		0.00	380.00	1	1	4	1				2				3		13.00	395.00	1	1																															4	1				2				3		25.00	395.00	1	1	4	1				2				3		0.00	140.00	1	1																4	1				2				3		0.00	125.00	1	1
H5425	803	0	1	01	01	H5425_803_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5425	804	0	1	01	01	H5425_804_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5425	806	0	1	01	01	H5425_806_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5425	807	0	1	01	01	H5425_807_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5427	052	0	1	01	01	H5427_052_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2																																																																																																											2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	059	0	1	01	01	H5427_059_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2																																																																																																											2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	060	0	1	01	01	H5427_060_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2																																																																																																											2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	070	0	1	01	01	H5427_070_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	072	0	1	01	01	H5427_072_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	077	0	1	01	01	H5427_077_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	078	0	1	01	01	H5427_078_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	1	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	082	0	1	01	01	H5427_082_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	083	0	1	01	01	H5427_083_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	087	0	1	01	01	H5427_087_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	1	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	088	0	1	01	01	H5427_088_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	089	0	1	01	01	H5427_089_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	091	0	1	01	01	H5427_091_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	093	0	1	01	01	H5427_093_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	094	0	1	01	01	H5427_094_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	096	0	1	01	01	H5427_096_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	099	0	1	01	01	H5427_099_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	102	0	1	01	01	H5427_102_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	103	0	1	01	01	H5427_103_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	105	0	1	01	01	H5427_105_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	106	0	1	01	01	H5427_106_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	107	0	1	01	01	H5427_107_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	108	0	1	01	01	H5427_108_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	112	0	1	02	01	H5427_112_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	113	0	1	02	01	H5427_113_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5431	001	0	1	01	01	H5431_001_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include: Up to 2 periapical dental x-rays every year. Up to 2 bitewing dental x-rays every year. Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	006	0	1	01	01	H5431_006_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include: Up to 2 periapical dental x-rays every year. Up to 2 bitewing dental x-rays every year. Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	012	0	1	01	01	H5431_012_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include: Up to 2 periapical dental x-rays every year. Up to 2 bitewing dental x-rays every year. Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	013	0	1	01	01	H5431_013_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include: Up to 2 periapical dental x-rays every year. Up to 2 bitewing dental x-rays every year. Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	017	0	1	01	01	H5431_017_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include: Up to 2 periapical dental x-rays every year. Up to 2 bitewing dental x-rays every year. Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	018	0	1	01	01	H5431_018_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include: Up to 2 periapical dental x-rays every year. Up to 2 bitewing dental x-rays every year. Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	019	0	1	01	01	H5431_019_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include: Up to 2 periapical dental x-rays every year. Up to 2 bitewing dental x-rays every year. Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	020	0	1	01	01	H5431_020_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include: Up to 2 periapical dental x-rays every year. Up to 2 bitewing dental x-rays every year. Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	021	0	1	01	01	H5431_021_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include: Up to 2 periapical dental x-rays every year. Up to 2 bitewing dental x-rays every year. Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	022	0	1	01	01	H5431_022_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include: Up to 2 periapical dental x-rays every year. Up to 2 bitewing dental x-rays every year. Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	026	0	1	01	01	H5431_026_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include: Up to 2 periapical dental x-rays every year. Up to 2 bitewing dental x-rays every year. Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5433	001	0	1	01	01	H5433_001_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		2	2	1	6	Restorative Crowns - 1 per tooth every 7 calendar years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Prosthodontics - Rebases for full or partial dentures covered once every 2 calendar years. Replacement of all teeth & acrylic on cast metal frame covered once every 3 calendar years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges) - 1 per tooth every 7 calendar years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	One consultation is covered every calendar year	2				1	0.00	0.00	0.00	1	2
H5434	002	0	1	04	01	H5434_002_0	12	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	023	0	1	04	01	H5434_023_0	10	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	024	0	1	04	01	H5434_024_0	12	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	025	0	1	04	01	H5434_025_0	12	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	026	0	1	04	01	H5434_026_0	12	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	030	0	1	04	01	H5434_030_0	10	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	031	0	1	04	01	H5434_031_0	12	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	034	0	1	04	01	H5434_034_0	12	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	035	0	1	04	01	H5434_035_0	12	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	036	0	1	04	01	H5434_036_0	12	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2								2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	038	0	1	04	01	H5434_038_0	9	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	040	0	1	04	01	H5434_040_0	9	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	041	0	1	04	01	H5434_041_0	9	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	042	0	1	04	01	H5434_042_0	9	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	044	0	1	04	01	H5434_044_0	9	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	045	0	1	04	01	H5434_045_0	12	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	046	0	1	04	01	H5434_046_0	9	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	047	0	1	04	01	H5434_047_0	9	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	048	0	1	04	01	H5434_048_0	8	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2								2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	801	0	1	04	01	H5434_801_0	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5434	802	0	1	04	01	H5434_802_0	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5434	806	0	1	04	01	H5434_806_0	7	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5434	807	0	1	04	01	H5434_807_0	7	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5435	001	0	1	09	04	H5435_001_0	2	2				1	20	20	20	2				2				1		500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00			1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2																					2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2																					2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2					
H5435	024	0	1	09	04	H5435_024_0	5	2				1	20	20	20	2				2				1		500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00			1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2																					2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2																					2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2					
H5439	010	0	1	04	01	H5439_010_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5439	011	0	1	04	01	H5439_011_0	5	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5439	015	0	1	04	01	H5439_015_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H5439	019	0	1	04	01	H5439_019_0	5	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H5439	023	0	1	04	01	H5439_023_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5447	001	0	1	01	01	H5447_001_0	5	2				2				1	15.00	15.00	15.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5447	002	0	1	01	01	H5447_002_0	5	2				1	20	20	20	2				2		2	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5447	003	0	1	01	01	H5447_003_0	6	2				1	20	20	20	2				2		2	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5453	001	0	1	04	01	H5453_001_0	7	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5453	002	0	1	04	01	H5453_002_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5453	003	0	1	04	01	H5453_003_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5453	004	0	1	04	01	H5453_004_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5453	005	0	1	04	01	H5453_005_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5453	010	0	1	04	01	H5453_010_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5453	011	0	1	04	01	H5453_011_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5453	015	0	1	04	01	H5453_015_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5453	016	0	1	04	01	H5453_016_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5453	017	0	1	04	01	H5453_017_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5453	018	0	1	04	01	H5453_018_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5453	019	0	1	04	01	H5453_019_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5453	020	0	1	04	01	H5453_020_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5453	021	0	1	04	01	H5453_021_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5453	022	0	1	04	01	H5453_022_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5453	023	0	1	04	01	H5453_023_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5453	024	0	1	04	01	H5453_024_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5471	118	0	1	01	01	H5471_118_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	125	0	1	01	01	H5471_125_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	135	0	1	01	01	H5471_135_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5472	001	0	1	02	01	H5472_001_0	11	2				2				2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	002	0	1	02	01	H5472_002_0	11	2				2				2				2		1	2	2							2				2					2					2		2	1				2				1	10.00	10.00	10.00	1	2	2	1				2				1	30.00	30.00	30.00	1	2																2	1				2				1	20.00	20.00	20.00	1	2	2	1				2				1	10.00	10.00	10.00	1	2																1	2		2000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	003	0	1	02	01	H5472_003_0	11	2				2				2				2		1	2	2							2				2					2					2		4	1				2				1	10.00	10.00	10.00	1	2	4	1				2				1	30.00	30.00	30.00	1	2																4	1				2				1	20.00	20.00	20.00	1	2	4	1				2				1	10.00	10.00	10.00	1	2																																																																																																																																																																																				
H5472	004	0	1	02	01	H5472_004_0	12	2				2				2				2		1	2	1		3600.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	007	0	1	02	01	H5472_007_0	10	2				2				2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	009	0	1	02	01	H5472_009_0	10	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	010	0	1	02	01	H5472_010_0	12	2				2				2				2		1	2	2							2				2					2					2		4	1				2				1	10.00	10.00	10.00	1	2	4	1				2				1	30.00	30.00	30.00	1	2																4	1				2				1	20.00	20.00	20.00	1	2	4	1				2				1	10.00	10.00	10.00	1	2																																																																																																																																																																																				
H5472	011	0	1	02	01	H5472_011_0	10	2				2				2				2		1	2	1		2200.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	012	0	1	02	01	H5472_012_0	8	2				2				2				2		1	2	2							2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																																																																																																																																																																																				
H5472	013	0	1	02	01	H5472_013_0	11	2				2				2				2		1	2	1		1800.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	801	0	1	01	01	H5472_801_0	4	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5472	802	0	1	01	01	H5472_802_0	4	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5472	803	0	1	01	01	H5472_803_0	4	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5472	804	0	1	01	01	H5472_804_0	4	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5475	001	0	1	02	01	H5475_001_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5475	026	0	1	02	01	H5475_026_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5475	031	0	1	02	01	H5475_031_0	4	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H5475	038	0	1	02	01	H5475_038_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5493	001	0	1	20	08	H5493_001_0	1																																																																																																																																																																																																																																																																																																						
H5493	002	0	1	20	08	H5493_002_0	1																																																																																																																																																																																																																																																																																																						
H5496	005	0	1	01	01	H5496_005_0	7	2				2				2				2		2	2	1		500.00	3		2		2				2					2					2		2	2	2	6	2 oral exams every calendar year1 intraoral exam every 3 years	2				2				2	2	2	2	1	6	Bitewings are covered once per calendar yearPanoramic radiographic images are covered once every 2 calendar yearsDiagnostic casts are covered once per calendar yearPeriapical x-rays are limited to 2 per calendar year	2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2		2					2		2	1				2				2				2	2	2	2	1	6	Endodontic covered services - 1 tooth per lifetimeRoot canals are limited to 2 procedures per calendar year.	2				2				2	2	2	2	1	6	Full mouth periodontal scaling is included in the 2 cleanings per year limitation.Other covered periodontal - 1 every 24 monthsSurgical perio services are covered once per quadrant every 3 calendar years	2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5496	012	0	1	01	01	H5496_012_0	9	2				2				2				2		2	2	1		500.00	3		2		2				2					2					2		2	2	2	6	2 oral exams every calendar year1 intraoral exam every 3 years	2				2				2	2	2	2	1	6	Bitewings are covered once per calendar yearPanoramic radiographic images are covered once every 2 calendar yearsDiagnostic casts are covered once per calendar yearPeriapical x-rays are limited to 2 per calendar year	2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2		2					2		2	1				2				2				2	2	2	2	1	6	Endodontic covered services - 1 tooth per lifetimeRoot canals are limited to 2 procedures per calendar year.	2				2				2	2	2	2	1	6	Full mouth periodontal scaling is included in the 2 cleanings per year limitation.Other covered periodontal - 1 every 24 monthsSurgical perio services are covered once per quadrant every 3 calendar years	2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5496	016	0	1	01	01	H5496_016_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5496	017	0	1	01	01	H5496_017_0	9	2				1	20	20	20	2				2		2	2	1		500.00	3		2		2				2					2					2		2	2	2	6	2 oral exams every calendar year1 intraoral exam every 3 years	2				2				2	2	2	2	1	6	Bitewings are covered once per calendar yearPanoramic radiographic images are covered once every 2 calendar yearsDiagnostic casts are covered once per calendar yearPeriapical x-rays are limited to 2 per calendar year	2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2		2					2		2	1				2				2				2	2	2	2	1	6	Endodontic covered services - 1 tooth per lifetimeRoot canals are limited to 2 procedures per calendar year.	2				2				2	2	2	2	1	6	Full mouth periodontal scaling is included in the 2 cleanings per year limitation.Other covered periodontal - 1 every 24 monthsSurgical perio services are covered once per quadrant every 3 calendar years	2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5521	015	0	1	04	01	H5521_015_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	016	0	1	04	01	H5521_016_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	020	0	1	04	01	H5521_020_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	022	0	1	04	01	H5521_022_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	033	0	1	04	01	H5521_033_0	4	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	037	0	1	04	01	H5521_037_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	055	0	1	04	01	H5521_055_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	077	0	1	04	01	H5521_077_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	081	0	1	04	01	H5521_081_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	084	0	1	04	01	H5521_084_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	085	0	1	04	01	H5521_085_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	086	0	1	04	01	H5521_086_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	087	0	1	04	01	H5521_087_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	088	0	1	04	01	H5521_088_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	089	0	1	04	01	H5521_089_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	091	0	1	04	01	H5521_091_0	3	2				2				1	59.00	59.00	59.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	095	0	1	04	01	H5521_095_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	099	0	1	04	01	H5521_099_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	116	0	1	04	01	H5521_116_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	119	0	1	04	01	H5521_119_0	3	2				2				1	55.00	55.00	55.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	120	0	1	04	01	H5521_120_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	121	0	1	04	01	H5521_121_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	123	0	1	04	01	H5521_123_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	124	0	1	04	01	H5521_124_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	139	0	1	04	01	H5521_139_0	3	2				2				1	41.00	41.00	41.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	140	0	1	04	01	H5521_140_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	150	0	1	04	01	H5521_150_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	156	0	1	04	01	H5521_156_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	157	0	1	04	01	H5521_157_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	159	0	1	04	01	H5521_159_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	160	0	1	04	01	H5521_160_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	169	0	1	04	01	H5521_169_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	170	0	1	04	01	H5521_170_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	171	0	1	04	01	H5521_171_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	194	0	1	04	01	H5521_194_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	195	0	1	04	01	H5521_195_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	207	0	1	04	01	H5521_207_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	211	0	1	04	01	H5521_211_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	214	0	1	04	01	H5521_214_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	215	0	1	04	01	H5521_215_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	218	0	1	04	01	H5521_218_0	3	2				2				1	37.00	37.00	37.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	219	0	1	04	01	H5521_219_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	223	0	1	04	01	H5521_223_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	227	0	1	04	01	H5521_227_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	229	0	1	04	01	H5521_229_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	231	0	1	04	01	H5521_231_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	233	0	1	04	01	H5521_233_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	235	0	1	04	01	H5521_235_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	236	0	1	04	01	H5521_236_0	3	2				2				1	56.00	56.00	56.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	241	0	1	04	01	H5521_241_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	243	0	1	04	01	H5521_243_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	245	0	1	04	01	H5521_245_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	246	0	1	04	01	H5521_246_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	249	0	1	04	01	H5521_249_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	250	0	1	04	01	H5521_250_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	251	0	1	04	01	H5521_251_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	254	0	1	04	01	H5521_254_0	3	2				2				1	56.00	56.00	56.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	261	0	1	04	01	H5521_261_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	263	0	1	04	01	H5521_263_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	269	0	1	04	01	H5521_269_0	4	2				2				1	67.00	67.00	67.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	270	0	1	04	01	H5521_270_0	4	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	271	0	1	04	01	H5521_271_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	272	0	1	04	01	H5521_272_0	4	2				2				1	72.00	72.00	72.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	275	0	1	04	01	H5521_275_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	277	0	1	04	01	H5521_277_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	279	0	1	04	01	H5521_279_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	285	0	1	04	01	H5521_285_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	286	0	1	04	01	H5521_286_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3750.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	289	0	1	04	01	H5521_289_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	296	0	1	04	01	H5521_296_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	299	0	1	04	01	H5521_299_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	302	0	1	04	01	H5521_302_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	303	0	1	04	01	H5521_303_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	305	0	1	04	01	H5521_305_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	306	0	1	04	01	H5521_306_0	3	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	319	0	1	04	01	H5521_319_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	320	0	1	04	01	H5521_320_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	322	0	1	04	01	H5521_322_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	323	0	1	04	01	H5521_323_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	324	0	1	04	01	H5521_324_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	326	0	1	04	01	H5521_326_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	329	0	1	04	01	H5521_329_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	3000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	330	0	1	04	01	H5521_330_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	340	0	1	04	01	H5521_340_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	348	0	1	04	01	H5521_348_0	3	2				2				1	56.00	56.00	56.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	351	0	1	04	01	H5521_351_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	352	0	1	04	01	H5521_352_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	353	0	1	04	01	H5521_353_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	3000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	364	0	1	04	01	H5521_364_0	3	2				2				1	59.00	59.00	59.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	365	0	1	04	01	H5521_365_0	3	2				2				1	49.00	49.00	49.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	375	0	1	04	01	H5521_375_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	378	0	1	04	01	H5521_378_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	381	0	1	04	01	H5521_381_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	388	0	1	04	01	H5521_388_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	392	0	1	04	01	H5521_392_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	395	0	1	04	01	H5521_395_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	398	0	1	04	01	H5521_398_0	3	2				1	20	20	20	2				2		1	2	1	2	2750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	399	0	1	04	01	H5521_399_0	3	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	400	0	1	04	01	H5521_400_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	403	0	1	04	01	H5521_403_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	404	0	1	04	01	H5521_404_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	406	0	1	04	01	H5521_406_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	407	0	1	04	01	H5521_407_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	414	0	1	04	01	H5521_414_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	431	0	1	04	01	H5521_431_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	433	0	1	04	01	H5521_433_0	4	2				2				1	60.00	60.00	60.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	434	0	1	04	01	H5521_434_0	4	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	435	0	1	04	01	H5521_435_0	4	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	439	0	1	04	01	H5521_439_0	4	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	443	0	1	04	01	H5521_443_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	446	0	1	04	01	H5521_446_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	449	0	1	04	01	H5521_449_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	450	0	1	04	01	H5521_450_0	3	2				2				1	70.00	70.00	70.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	451	0	1	04	01	H5521_451_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	457	0	1	04	01	H5521_457_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	461	0	1	04	01	H5521_461_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	464	0	1	04	01	H5521_464_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	465	0	1	04	01	H5521_465_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	467	0	1	04	01	H5521_467_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	470	0	1	04	01	H5521_470_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	475	0	1	04	01	H5521_475_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	476	0	1	04	01	H5521_476_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	477	0	1	04	01	H5521_477_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	487	0	1	04	01	H5521_487_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	488	0	1	04	01	H5521_488_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	490	0	1	04	01	H5521_490_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	496	0	1	04	01	H5521_496_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	501	0	1	04	01	H5521_501_0	3	2				2				1	46.00	46.00	46.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	502	0	1	04	01	H5521_502_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	504	0	1	04	01	H5521_504_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	510	0	1	04	01	H5521_510_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	512	0	1	04	01	H5521_512_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	520	0	1	04	01	H5521_520_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	521	0	1	04	01	H5521_521_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	536	0	1	04	01	H5521_536_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	553	0	1	04	01	H5521_553_0	3	2				2				1	49.00	49.00	49.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	554	0	1	04	01	H5521_554_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	558	0	1	04	01	H5521_558_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	569	0	1	04	01	H5521_569_0	4	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	609	0	1	04	01	H5521_609_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	645	0	1	04	01	H5521_645_0	3	2				2				1	59.00	59.00	59.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	646	0	1	04	01	H5521_646_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	649	0	1	04	01	H5521_649_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	650	0	1	04	01	H5521_650_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	652	0	1	04	01	H5521_652_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	654	0	1	04	01	H5521_654_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	661	0	1	04	01	H5521_661_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	669	0	1	04	01	H5521_669_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	674	0	1	04	01	H5521_674_0	3	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	686	0	1	04	01	H5521_686_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	687	0	1	04	01	H5521_687_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	698	0	1	04	01	H5521_698_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	699	0	1	04	01	H5521_699_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	702	0	1	04	01	H5521_702_0	4	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	705	0	1	04	01	H5521_705_0	4	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	706	0	1	04	01	H5521_706_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	710	0	1	04	01	H5521_710_0	4	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	721	0	1	04	01	H5521_721_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	722	0	1	04	01	H5521_722_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	723	0	1	04	01	H5521_723_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	3000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	724	0	1	04	01	H5521_724_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	725	0	1	04	01	H5521_725_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	726	0	1	04	01	H5521_726_0	3	2				2				1	38.00	38.00	38.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	727	0	1	04	01	H5521_727_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	728	0	1	04	01	H5521_728_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	729	0	1	04	01	H5521_729_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	736	0	1	04	01	H5521_736_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	738	0	1	04	01	H5521_738_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	739	0	1	04	01	H5521_739_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	740	0	1	04	01	H5521_740_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	742	0	1	04	01	H5521_742_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	743	0	1	04	01	H5521_743_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	744	0	1	04	01	H5521_744_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	745	0	1	04	01	H5521_745_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	746	0	1	04	01	H5521_746_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	747	0	1	04	01	H5521_747_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	748	0	1	04	01	H5521_748_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	749	0	1	04	01	H5521_749_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	750	0	1	04	01	H5521_750_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	751	0	1	04	01	H5521_751_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5521	752	0	1	04	01	H5521_752_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	754	0	1	04	01	H5521_754_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	755	0	1	04	01	H5521_755_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5521	756	0	1	04	01	H5521_756_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	757	0	1	04	01	H5521_757_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	758	0	1	04	01	H5521_758_0	3	2				1	20	20	20	2				2		1	2	1	2	1900.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	759	0	1	04	01	H5521_759_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	760	0	1	04	01	H5521_760_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	761	0	1	04	01	H5521_761_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	762	0	1	04	01	H5521_762_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	801	0	1	04	01	H5521_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5521	805	0	2	04	01	H5521_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	001	0	1	04	01	H5522_001_0	4	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	002	0	1	04	01	H5522_002_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	004	0	1	04	01	H5522_004_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	005	0	1	04	01	H5522_005_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	013	0	1	04	01	H5522_013_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	014	0	1	04	01	H5522_014_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	017	0	1	04	01	H5522_017_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5522	022	0	1	04	01	H5522_022_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5522	028	0	1	04	01	H5522_028_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5522	032	0	1	04	01	H5522_032_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	802	0	1	04	01	H5522_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	803	0	1	04	01	H5522_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	808	0	2	04	01	H5522_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	809	0	2	04	01	H5522_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	810	0	1	04	01	H5522_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	811	0	1	04	01	H5522_811_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	813	0	2	04	01	H5522_813_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	814	0	2	04	01	H5522_814_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	815	0	1	04	01	H5522_815_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	816	0	1	04	01	H5522_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	817	0	2	04	01	H5522_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	818	0	2	04	01	H5522_818_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	819	0	1	04	01	H5522_819_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	828	0	1	04	01	H5522_828_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	832	0	1	04	01	H5522_832_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	837	0	1	04	01	H5522_837_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	838	0	2	04	01	H5522_838_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	839	0	1	04	01	H5522_839_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5522	840	0	1	04	01	H5522_840_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5525	004	0	1	04	01	H5525_004_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	005	0	1	04	01	H5525_005_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5525	006	0	1	04	01	H5525_006_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	008	0	1	04	01	H5525_008_0	4	2				2				1	60.00	60.00	60.00	2		1	2	1	2	500.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	030	0	1	04	01	H5525_030_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	031	0	1	04	01	H5525_031_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	034	0	1	04	01	H5525_034_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	035	0	1	04	01	H5525_035_0	6	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	036	0	1	04	01	H5525_036_0	4	2				1	20	20	20	2				2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	042	0	1	04	01	H5525_042_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	045	0	1	04	01	H5525_045_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	049	0	1	04	01	H5525_049_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	051	1	1	04	01	H5525_051_1	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	051	2	1	04	01	H5525_051_2	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	054	0	1	04	01	H5525_054_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	056	0	1	04	01	H5525_056_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	057	0	1	04	01	H5525_057_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	059	0	1	04	01	H5525_059_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5525	065	0	1	04	01	H5525_065_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	070	0	1	04	01	H5525_070_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	072	0	1	04	01	H5525_072_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	074	0	1	04	01	H5525_074_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	075	0	1	04	01	H5525_075_0	5	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	078	0	1	04	01	H5525_078_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5525	079	0	1	04	01	H5525_079_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5525	080	0	1	04	01	H5525_080_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	084	0	1	04	01	H5525_084_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	085	1	1	04	01	H5525_085_1	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	085	2	1	04	01	H5525_085_2	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5525	086	1	1	04	01	H5525_086_1	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5525	086	2	1	04	01	H5525_086_2	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	087	0	1	04	01	H5525_087_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5525	809	0	1	04	01	H5525_809_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5525	810	0	1	04	01	H5525_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5525	812	0	2	04	01	H5525_812_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5525	813	0	2	04	01	H5525_813_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5525	816	0	1	04	01	H5525_816_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5525	817	0	1	04	01	H5525_817_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5525	818	0	1	04	01	H5525_818_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5525	819	0	1	04	01	H5525_819_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5525	826	0	1	04	01	H5525_826_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5525	827	0	1	04	01	H5525_827_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5525	830	0	1	04	01	H5525_830_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5525	831	0	1	04	01	H5525_831_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5526	023	0	1	04	01	H5526_023_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.  Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H5526	806	0	1	04	01	H5526_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5526	808	0	1	04	01	H5526_808_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5526	813	0	1	04	01	H5526_813_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5528	807	0	1	04	01	H5528_807_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5528	815	0	1	04	01	H5528_815_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5533	003	0	1	04	01	H5533_003_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				1	15.00	15.00	15.00	2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				1	15.00	15.00	15.00	2	2																2	2	2	3		2				2				2	2																															1	2	2	2000.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				2				2				2	2																														
H5533	005	0	1	04	01	H5533_005_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				1	15.00	15.00	15.00	2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				1	15.00	15.00	15.00	2	2																2	2	2	3		2				2				2	2																															1	2	2	1000.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	008	0	1	04	01	H5533_008_0	8	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				1	15.00	15.00	15.00	2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				1	15.00	15.00	15.00	2	2																2	2	2	3		2				2				2	2																															1	2	2	2500.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	013	0	1	04	01	H5533_013_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1375.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	016	1	1	04	01	H5533_016_1	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	3000.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	016	2	1	04	01	H5533_016_2	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	3000.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	017	1	1	04	01	H5533_017_1	8	2				2				1	45.00	45.00	45.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	2500.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	017	2	1	04	01	H5533_017_2	6	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1000.00	3				2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	019	0	1	04	01	H5533_019_0	6	2				2				1	20.00	20.00	20.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	6000.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	020	0	1	04	01	H5533_020_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	2000.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	801	0	1	04	01	H5533_801_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5533	802	0	1	04	01	H5533_802_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5533	803	0	1	04	01	H5533_803_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5538	001	0	1	20	08	H5538_001_0	1																																																																																																																																																																																																																																																																																																						
H5538	002	0	1	20	08	H5538_002_0	1																																																																																																																																																																																																																																																																																																						
H5549	003	0	1	01	01	H5549_003_0	10	2				2				2				2		2	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	2		3500.00	3		2		2					2		2	2	2	3		2				2				1	2																															2	2	2	3		2				2				1	2																2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																														
H5549	011	0	1	01	01	H5549_011_0	10	2				2				2				2		2	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	2		2750.00	3		2		2					2		2	2	2	3		2				2				1	2																															2	2	2	3		2				2				1	2																2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																														
H5549	012	0	1	01	01	H5549_012_0	10	2				2				2				2		2	2	2							2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	2		2500.00	3		2		2					2		2	2	2	3		2				2				1	2																															2	2	2	3		2				2				1	2																2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																														
H5577	002	0	1	01	01	H5577_002_0	9	2				2				2				2		2	2																																																																																																																		1	2		4000.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	005	0	1	01	01	H5577_005_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		2750.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	008	0	1	02	01	H5577_008_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		3500.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	016	0	1	01	01	H5577_016_0	5	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		2500.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	017	0	1	01	01	H5577_017_0	7	2				2				2				2		2	2																																																																																																																		1	2		4500.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	038	0	1	01	01	H5577_038_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		3000.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	042	0	1	01	01	H5577_042_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		3000.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	043	0	1	01	01	H5577_043_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		3000.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	044	0	1	01	01	H5577_044_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		3400.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	046	0	1	01	01	H5577_046_0	7	2				2				2				2		2	2																																																																																																																		1	2		1200.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	052	0	1	01	01	H5577_052_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		2500.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	054	1	1	01	01	H5577_054_1	9	2				2				2				2		2	2																																																																																																																		1	2		1200.00	3				2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	054	2	1	01	01	H5577_054_2	8	2				2				2				2		2	2																																																																																																																		1	2		1200.00	3				2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	054	3	1	01	01	H5577_054_3	8	2				2				2				2		2	2																																																																																																																		1	2		1200.00	3				2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	056	1	1	01	01	H5577_056_1	10	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		1500.00	3				2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	056	2	1	01	01	H5577_056_2	8	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		1500.00	3				2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	056	4	1	01	01	H5577_056_4	9	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		1500.00	3				2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	059	0	1	01	01	H5577_059_0	8	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		2500.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	060	0	1	01	01	H5577_060_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		2700.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	062	0	1	01	01	H5577_062_0	7	2				2				2				2		2	2																																																																																																																		1	2		500.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	063	0	1	01	01	H5577_063_0	8	2				2				2				2		2	2																																																																																																																		1	2		1000.00	3		2		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	801	0	1	01	01	H5577_801_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5577	802	0	1	01	01	H5577_802_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5577	809	0	1	01	01	H5577_809_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5577	818	0	1	01	01	H5577_818_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5577	821	0	1	01	01	H5577_821_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5577	824	0	1	01	01	H5577_824_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5577	827	0	1	01	01	H5577_827_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5577	829	0	1	01	01	H5577_829_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5577	830	0	1	01	01	H5577_830_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5577	831	0	1	01	01	H5577_831_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5577	833	1	1	02	01	H5577_833_1	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5577	833	2	1	02	01	H5577_833_2	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5577	833	3	1	02	01	H5577_833_3	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5577	833	4	1	02	01	H5577_833_4	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5577	833	5	1	02	01	H5577_833_5	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5577	833	6	1	02	01	H5577_833_6	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5577	833	7	1	02	01	H5577_833_7	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5577	833	8	1	02	01	H5577_833_8	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5577	833	9	1	02	01	H5577_833_9	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5577	833	10	1	02	01	H5577_833_10	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5577	838	0	1	01	01	H5577_838_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5580	001	0	1	01	01	H5580_001_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		5000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H5580	004	0	1	01	01	H5580_004_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		5000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H5580	005	0	1	01	01	H5580_005_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		5000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H5587	002	0	1	01	01	H5587_002_0	8	2				1	20	20	20	2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5590	012	1	1	01	01	H5590_012_1	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3				2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5590	012	2	1	01	01	H5590_012_2	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3				2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5591	003	0	1	01	01	H5591_003_0	5	2				2				2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				1	20	20	20	2				2	2	2	2	2	3		2				2				2	2																2	1				1	20	20	20	2				2	2	1	1							2					2		2	1				1	50	50	50	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	50	50	50	2				1	1	2	1				1	50	50	50	2				1	1																2	1				1	50	50	50	2				1	1	2	1				1	50	50	50	2				1	1																														
H5591	017	0	1	01	01	H5591_017_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2		2				2					1	110100	50.00	50.00	50.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	2	2	2	3		2								2	2																2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1							2					2		2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																														
H5591	018	0	1	01	01	H5591_018_0	6	2				2				1	55.00	55.00	55.00	2		1	2																																																																																																																																																																																																																																																																																						
H5591	019	0	1	01	01	H5591_019_0	6	2				2				1	55.00	55.00	55.00	2		1	2																																																																																																																																																																																																																																																																																						
H5591	020	0	1	01	01	H5591_020_0	5	2				2				1	55.00	55.00	55.00	2		1	2																																																																																																																																																																																																																																																																																						
H5591	021	0	1	01	01	H5591_021_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2		2				2					1	110100	50.00	50.00	50.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	2	2	2	3		2								2	2																2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1							2					2		2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																														
H5591	022	0	1	01	01	H5591_022_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2		2				2					1	110100	50.00	50.00	50.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	2	2	2	3		2								2	2																2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1							2					2		2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																														
H5591	801	0	1	02	01	H5591_801_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5591	802	0	1	02	01	H5591_802_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5593	001	0	1	01	01	H5593_001_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5593	003	0	1	01	01	H5593_003_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5593	004	0	1	01	01	H5593_004_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5593	005	0	1	01	01	H5593_005_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5593	006	0	1	01	01	H5593_006_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5593	007	0	1	01	01	H5593_007_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5593	008	0	1	01	01	H5593_008_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5593	009	0	1	01	01	H5593_009_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5593	801	0	1	01	01	H5593_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5594	001	0	1	01	01	H5594_001_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	002	0	1	01	01	H5594_002_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	016	0	1	01	01	H5594_016_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	1	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	017	0	1	01	01	H5594_017_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	1	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	019	0	1	01	01	H5594_019_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	022	0	1	01	01	H5594_022_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	026	0	1	01	01	H5594_026_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	028	0	1	01	01	H5594_028_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	029	0	1	01	01	H5594_029_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	030	0	1	01	01	H5594_030_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	031	0	1	01	01	H5594_031_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	032	0	1	01	01	H5594_032_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	036	0	1	01	01	H5594_036_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2								2					2		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	1	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5599	002	0	1	02	01	H5599_002_0	5	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5599	003	0	1	01	01	H5599_003_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 60 months or by report	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 3 months to 6 months	2				1	0.00	0.00	0.00	1	2	2	2	2	6	Every 12 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	Every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H5599	004	0	1	02	01	H5599_004_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H5599	010	0	1	02	01	H5599_010_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5599	014	0	1	01	01	H5599_014_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 60 months or by report	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 3 months to 6 months	2				1	0.00	0.00	0.00	1	2	2	2	2	6	Every 12 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	Every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H5599	015	0	1	01	01	H5599_015_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 60 months or by report	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 3 months to 6 months	2				1	0.00	0.00	0.00	1	2	2	2	2	6	Every 12 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	Every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H5599	016	0	1	01	01	H5599_016_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 60 months or by report	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 3 months to 6 months	2				1	0.00	0.00	0.00	1	2	2	2	2	6	Every 12 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	Every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H5599	017	0	1	01	01	H5599_017_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 60 months or by report	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 3 months to 6 months	2				1	0.00	0.00	0.00	1	2	2	2	2	6	Every 12 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	Every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H5608	001	0	1	01	01	H5608_001_0	7	2				1	20	20	20	2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Full Mouth XRay: 1/60 monthsIntraoral/Periapical X-Ray: 1/calendar yr, each addl 1/calendar yrBitewing XRay: 1,2,3,4 films 1/calendar yr Vertical bitewing: 7-8 films 1/calendar yr Pano Xray: 1/3 yrs	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	1	6	Filling (amalgam or resin-based composite indirect) 1 per tooth calendar year	2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontal Scaling and Root Planing 1 in 24 monthsPeriodontal Maintenance 1 in 24 monthsFull Mouth Debridement 1 per 3 years	2				2				2	2																																																													2	2	1	6	Gingivectomy or gingivoplasty, Gingival flap, including root planing, Osseous surgery, Bone replacement graft, Free soft tissue graft - 1 in 36 months	2				2				2	2																														
H5608	002	0	1	01	01	H5608_002_0	7	2				2				1	35.00	35.00	35.00	2		2	2	1		2000.00	3		2		2				2	000000				2					1	25.00	2	2	2	3		2				2				2	2	2	2	1	6	Full mouth radiographic image 1/36 mosIntraoral periapical x-ray 4/yrIntraoral occlusal x-ray 1/60 mosBitewing x-ray 1/yrVertical bitewings - 7-8 films 1/yrPanoramic film 1/3 yrs	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					1	25.00	2	2	2	6	Limited to 2 filling services per year.	1	40	40	40	2				2	2																2	2	1	2		1	40	40	40	2				2	2																																																																																																									
H5610	001	0	1	20	08	H5610_001_0	1																																																																																																																																																																																																																																																																																																						
H5610	003	0	1	20	08	H5610_003_0	1																																																																																																																																																																																																																																																																																																						
H5619	001	0	1	01	01	H5619_001_0	4	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5619	003	0	1	01	01	H5619_003_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	012	0	1	01	01	H5619_012_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H5619	015	0	1	01	01	H5619_015_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H5619	016	0	1	01	01	H5619_016_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H5619	021	0	1	01	01	H5619_021_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H5619	026	0	1	01	01	H5619_026_0	4	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	1	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H5619	038	0	1	01	01	H5619_038_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	0.00	0.00	0.00	1	1																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H5619	046	0	1	01	01	H5619_046_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	047	0	1	01	01	H5619_047_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	051	0	1	02	01	H5619_051_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5619	055	0	1	01	01	H5619_055_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	057	0	1	01	01	H5619_057_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5619	061	0	1	01	01	H5619_061_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5619	066	0	1	01	01	H5619_066_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5619	069	0	1	02	01	H5619_069_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	075	0	1	01	01	H5619_075_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	089	0	1	01	01	H5619_089_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	090	0	1	01	01	H5619_090_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5619	091	0	1	01	01	H5619_091_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5619	093	0	1	01	01	H5619_093_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	095	0	1	01	01	H5619_095_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	111	0	1	02	01	H5619_111_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	113	0	1	02	01	H5619_113_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	116	0	1	01	01	H5619_116_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H5619	119	0	1	01	01	H5619_119_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H5619	121	0	1	01	01	H5619_121_0	4	2				2				1	10.00	10.00	10.00	2		1	1	1		1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	1	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	1	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H5619	122	0	1	01	01	H5619_122_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	123	0	1	02	01	H5619_123_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	126	0	1	02	01	H5619_126_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	133	0	1	01	01	H5619_133_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	135	0	1	01	01	H5619_135_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	137	0	1	01	01	H5619_137_0	6	2				2				1	75.00	75.00	75.00	2		1	2	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5619	143	0	1	01	01	H5619_143_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	145	0	1	01	01	H5619_145_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5619	146	0	1	01	01	H5619_146_0	4	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H5619	147	0	1	01	01	H5619_147_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H5619	150	0	1	01	01	H5619_150_0	4	2				2				1	30.00	30.00	30.00	2		1	1	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H5619	151	0	1	01	01	H5619_151_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5619	152	0	1	01	01	H5619_152_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5619	157	0	1	01	01	H5619_157_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5619	159	0	1	01	01	H5619_159_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H5619	161	0	1	01	01	H5619_161_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	162	0	1	02	01	H5619_162_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	163	0	1	01	01	H5619_163_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	165	0	1	01	01	H5619_165_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	166	0	1	01	01	H5619_166_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	167	0	1	01	01	H5619_167_0	4	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	169	0	1	01	01	H5619_169_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5619	171	0	1	01	01	H5619_171_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	174	0	1	01	01	H5619_174_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	177	0	1	01	01	H5619_177_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H5619	178	0	1	01	01	H5619_178_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H5619	179	0	1	02	01	H5619_179_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	0.00	0.00	0.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5619	180	0	1	01	01	H5619_180_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5619	181	0	1	01	01	H5619_181_0	4	2				2				1	40.00	40.00	40.00	2		1	1	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	1	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H5619	182	0	1	01	01	H5619_182_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	183	0	1	01	01	H5619_183_0	4	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	1	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H5619	184	0	1	01	01	H5619_184_0	4	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H5619	185	0	1	01	01	H5619_185_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5619	186	0	1	01	01	H5619_186_0	4	2				2				1	75.00	75.00	75.00	2		1	2	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5619	188	1	1	01	01	H5619_188_1	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	188	2	1	01	01	H5619_188_2	4	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	189	1	1	02	01	H5619_189_1	4	2				2				1	35.00	35.00	35.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	189	2	1	02	01	H5619_189_2	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5619	190	0	1	01	01	H5619_190_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	191	1	1	01	01	H5619_191_1	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H5619	191	2	1	01	01	H5619_191_2	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H5619	191	3	1	01	01	H5619_191_3	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H5619	802	0	1	01	01	H5619_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5619	803	0	1	01	01	H5619_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5619	805	0	1	01	01	H5619_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5619	806	0	1	01	01	H5619_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5622	001	0	1	20	08	H5622_001_0	1																																																																																																																																																																																																																																																																																																						
H5622	002	0	1	20	08	H5622_002_0	1																																																																																																																																																																																																																																																																																																						
H5628	001	0	1	01	01	H5628_001_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H5628	013	1	1	01	01	H5628_013_1	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5628	013	2	1	01	01	H5628_013_2	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5629	001	0	1	20	08	H5629_001_0	1																																																																																																																																																																																																																																																																																																						
H5629	002	0	1	20	08	H5629_002_0	1																																																																																																																																																																																																																																																																																																						
H5644	801	0	1	01	01	H5644_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	802	0	1	01	01	H5644_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	803	0	1	01	01	H5644_803_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	804	0	1	01	01	H5644_804_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	805	0	1	01	01	H5644_805_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	806	0	1	01	01	H5644_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	807	0	1	01	01	H5644_807_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	808	0	1	01	01	H5644_808_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	809	0	1	01	01	H5644_809_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	810	0	1	01	01	H5644_810_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	811	0	1	01	01	H5644_811_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	812	0	1	01	01	H5644_812_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	813	0	1	01	01	H5644_813_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	814	0	1	01	01	H5644_814_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	815	0	1	01	01	H5644_815_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	816	0	1	01	01	H5644_816_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	817	0	1	01	01	H5644_817_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	818	0	1	01	01	H5644_818_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	819	0	1	01	01	H5644_819_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	820	0	1	01	01	H5644_820_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5644	821	0	1	01	01	H5644_821_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5652	009	0	1	02	01	H5652_009_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H5692	001	0	1	01	01	H5692_001_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5703	001	0	1	01	01	H5703_001_0	7	2				1	20	20	20	2				2		1	2																																																																																																																		2								2					2		2	2	1	3		2				2				2	2																																																																																																																																							
H5718	001	0	1	04	01	H5718_001_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5718	002	0	1	04	01	H5718_002_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H5718	003	0	1	04	01	H5718_003_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5718	004	0	1	04	01	H5718_004_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5718	005	0	1	04	01	H5718_005_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5718	006	0	1	04	01	H5718_006_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5718	008	0	1	04	01	H5718_008_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5718	009	0	1	04	01	H5718_009_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5718	010	0	1	04	01	H5718_010_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5718	011	0	1	04	01	H5718_011_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H5734	001	0	1	01	01	H5734_001_0	6	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5767	001	0	1	01	01	H5767_001_0	10	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	2	3		3		20	50	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	50	50	50	2				1	1	2	1				1	20	20	20	2				1	1																															2	1				1	20	20	20	2				1	1																														
H5767	002	0	1	01	01	H5767_002_0	10	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	2	3		3		20	50	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	50	50	50	2				1	1	2	1				1	20	20	20	2				1	1																															2	1				1	20	20	20	2				1	1																														
H5767	003	0	1	01	01	H5767_003_0	10	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	2	3		3		20	50	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	50	50	50	2				1	1	2	1				1	20	20	20	2				1	1																															2	1				1	20	20	20	2				1	1																														
H5774	022	0	1	01	01	H5774_022_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA). One (1) every 6 months, for minors under 19 years and adults who have lost salivary function.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				2	2	1	2		3050.00	3		2		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	031	0	1	02	01	H5774_031_0	11	2				2				2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA). One (1) every 6 months, for minors under 19 years and adults who have lost salivary function.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				2	2	1	2		3000.00	3		2		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	035	0	1	01	01	H5774_035_0	12	2				2				2				2		1	2																																																																																																																		1	2		1625.00	3		2		2					2		2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	038	0	1	01	01	H5774_038_0	10	2				2				2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA). One (1) every 6 months, for minors under 19 years and adults who have lost salivary function.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				2	2	1	2		1600.00	3		2		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	041	1	1	01	01	H5774_041_1	12	2				2				2				2		1	2																																																																																																																		1	2		1200.00	3				2					2		2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	041	2	1	01	01	H5774_041_2	11	2				2				2				2		1	2																																																																																																																		1	2		1200.00	3				2					2		2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	041	3	1	01	01	H5774_041_3	11	2				2				2				2		1	2																																																																																																																		1	2		1200.00	3				2					2		2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	043	1	1	01	01	H5774_043_1	11	2				2				2				2		1	2																																																																																																																		1	2		2400.00	3				2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	043	2	1	01	01	H5774_043_2	11	2				2				2				2		1	2																																																																																																																		1	2		2400.00	3				2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	043	3	1	01	01	H5774_043_3	11	2				2				2				2		1	2																																																																																																																		1	2		2400.00	3				2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	046	0	1	01	01	H5774_046_0	9	2				2				2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA). One (1) every 6 months, for minors under 19 years and adults who have lost salivary function.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				2	2	1	2		2500.00	3		2		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	047	1	1	01	01	H5774_047_1	12	2				2				2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA). One (1) every 6 months, for minors under 19 years and adults who have lost salivary function.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	1	2		2600.00	3				2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA)	2				2				1	2
H5774	047	2	1	01	01	H5774_047_2	11	2				2				2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA). One (1) every 6 months, for minors under 19 years and adults who have lost salivary function.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	1	2		2000.00	3				2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA)	2				2				1	2
H5774	047	3	1	01	01	H5774_047_3	11	2				2				2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA). One (1) every 6 months, for minors under 19 years and adults who have lost salivary function.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	1	2		2000.00	3				2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA)	2				2				1	2
H5774	049	0	1	01	01	H5774_049_0	12	2				2				2				2		1	2																																																																																																																		1	2		1600.00	3		2		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	050	0	1	01	01	H5774_050_0	11	2				2				2				2		1	2																																																																																																																		1	2		650.00	3		2		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American DentalAssociation (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American DentalAssociation (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American DentalAssociation (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American DentalAssociation (ADA).	2				2				1	2																																														2	2	1	6	Services are administered with the CDT codes and procedures established by the American DentalAssociation (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American DentalAssociation (ADA).	2				2				1	2
H5774	802	0	1	01	01	H5774_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	808	0	1	01	01	H5774_808_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	809	0	1	02	01	H5774_809_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	810	0	1	01	01	H5774_810_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	811	0	1	02	01	H5774_811_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	812	0	1	02	01	H5774_812_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	814	0	1	02	01	H5774_814_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	816	0	1	02	01	H5774_816_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	818	0	1	02	01	H5774_818_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	820	0	1	02	01	H5774_820_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	821	0	1	02	01	H5774_821_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	822	0	1	02	01	H5774_822_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	823	0	1	02	01	H5774_823_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	824	0	1	02	01	H5774_824_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	825	0	1	02	01	H5774_825_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	826	0	1	01	01	H5774_826_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	827	0	1	01	01	H5774_827_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	828	0	1	01	01	H5774_828_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	829	0	1	01	01	H5774_829_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	830	0	1	01	01	H5774_830_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5774	831	0	1	01	01	H5774_831_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5779	007	0	1	01	01	H5779_007_0	4	2				2				3		10.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H5779	009	0	1	01	01	H5779_009_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	1	20	20	20	2				1	2	2	2	1	6	Once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	Every 6 months to 2 years	1	20	20	20	2				1	2	2	2	1	6	Every year to 5 years	1	20	20	20	2				1	2																																														2	2	1	6	Per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	Every date of service to every 5 years	1	20	20	20	2				1	2
H5779	010	0	1	01	01	H5779_010_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	1	40	40	40	2				1	2	2	2	1	6	Once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	Every 6 months to 2 years	1	40	40	40	2				1	2	2	2	1	6	Every year to 5 years	1	40	40	40	2				1	2																																														2	2	1	6	Per tooth per lifetime	1	40	40	40	2				1	2																2	2	1	6	Every date of service to every 5 years	1	40	40	40	2				1	2
H5793	001	0	1	02	01	H5793_001_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5793	014	0	1	02	01	H5793_014_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5793	017	0	1	02	01	H5793_017_0	3	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5793	018	0	1	02	01	H5793_018_0	3	2				2				1	75.00	75.00	75.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5793	019	0	1	02	01	H5793_019_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5793	020	0	1	02	01	H5793_020_0	3	2				1	30	30	30	2				2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H5793	801	0	1	01	01	H5793_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5793	802	0	1	01	01	H5793_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5793	805	0	1	01	01	H5793_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5822	001	0	1	20	08	H5822_001_0	1																																																																																																																																																																																																																																																																																																						
H5822	002	0	1	20	08	H5822_002_0	1																																																																																																																																																																																																																																																																																																						
H5823	013	1	1	01	01	H5823_013_1	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2500.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H5823	013	2	1	01	01	H5823_013_2	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H5823	015	0	1	01	01	H5823_015_0	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5826	014	0	1	01	01	H5826_014_0	6	2				1	20	20	20	2				2		2	2	1		2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5826	017	0	1	01	01	H5826_017_0	6	2				1	20	20	20	2				2		2	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5828	001	0	1	01	01	H5828_001_0	5	2				1	20	20	20	2				2		1	2	1		6000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5828	002	0	1	01	01	H5828_002_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5828	008	0	1	02	01	H5828_008_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	013	0	1	02	01	H5828_013_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	014	0	1	02	01	H5828_014_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2250.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	015	0	1	02	01	H5828_015_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	016	0	1	02	01	H5828_016_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	017	0	1	02	01	H5828_017_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	018	0	1	01	01	H5828_018_0	5	2				1	20	20	20	2				2		1	2	1		6000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5843	001	0	1	01	01	H5843_001_0	6	2				1	20	20	20	2				2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	1 bitewing (1-4) images per 12 mos.  1 intraoral-complete series of radiographic images, vertical bitewings, panoramic image every 36 mos.  2 intraoral-occlusal radiographic images per 24 mos.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	See note.	1	50	50	50	2				1	2	2	2	1	6	Pulpotomy or pupal debridement, root canals, apicoectomy, retrograde filling-1 per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	See note.	1	50	50	50	2				1	2	2	2	1	6	See note.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				1	2																2	2	1	6	Fixed dentures (bridges) and retainers-1 per tooth per 60 monthsRe-cement, rebond or repair partial dentures- 1 per 24 months after 6 months of placement	1	50	50	50	2				1	2	2	2	1	6	See note.	1	50	50	50	2				1	2																2	2	1	6	See note.	1	50	50	50	2				1	2
H5852	001	0	1	01	01	H5852_001_0	8	2				2				2				2		1	1	2							2				2					2					2		2	1				2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1550.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5854	012	0	1	02	01	H5854_012_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5854	013	0	1	01	01	H5854_013_0	4	2				1	20	20	20	2				2		1	2	1		1200.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5854	018	0	1	02	01	H5854_018_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5854	019	1	1	01	01	H5854_019_1	5	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																						
H5854	019	2	1	01	01	H5854_019_2	5	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																						
H5854	020	0	1	01	01	H5854_020_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5854	801	0	1	01	01	H5854_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5854	803	0	1	01	01	H5854_803_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5854	806	0	2	01	01	H5854_806_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5854	807	0	2	01	01	H5854_807_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5854	809	0	1	01	01	H5854_809_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5854	811	0	2	01	01	H5854_811_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5859	001	0	1	01	01	H5859_001_0	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5883	002	1	1	02	01	H5883_002_1	9	2				2				3		0.00	225.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	002	2	1	02	01	H5883_002_2	8	2				2				3		0.00	225.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	002	3	1	02	01	H5883_002_3	8	2				2				3		0.00	225.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	002	4	1	02	01	H5883_002_4	8	2				2				3		0.00	225.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	002	7	1	02	01	H5883_002_7	8	2				2				3		0.00	225.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	003	1	1	02	01	H5883_003_1	9	2				2				3		0.00	200.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical & Full Mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	003	2	1	02	01	H5883_003_2	8	2				2				3		0.00	200.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical & Full Mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	003	3	1	02	01	H5883_003_3	8	2				2				3		0.00	200.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical & Full Mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	003	4	1	02	01	H5883_003_4	8	2				2				3		0.00	200.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical & Full Mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	003	5	1	02	01	H5883_003_5	8	2				2				3		0.00	200.00	2		2	2	1		1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical & Full Mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	007	0	1	01	01	H5883_007_0	10	2				2				3		0.00	225.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical. Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	014	1	1	02	01	H5883_014_1	11	2				2				3		0.00	375.00	2		2	2	1		950.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	014	2	1	02	01	H5883_014_2	10	2				2				3		0.00	375.00	2		2	2	1		950.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	014	4	1	02	01	H5883_014_4	10	2				2				3		0.00	375.00	2		2	2	1		950.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	014	5	1	02	01	H5883_014_5	10	2				2				3		0.00	375.00	2		2	2	1		950.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	017	0	1	02	01	H5883_017_0	7	2				2				3		0.00	200.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H5883	801	0	1	02	01	H5883_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5883	805	0	1	02	01	H5883_805_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5902	001	0	1	20	08	H5902_001_0	1																																																																																																																																																																																																																																																																																																						
H5902	002	0	1	20	08	H5902_002_0	1																																																																																																																																																																																																																																																																																																						
H5926	001	0	1	01	01	H5926_001_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H5926	008	0	1	01	01	H5926_008_0	8	2				1	20	20	20	2				2		2	2																																																																																																																		1	2		4000.00	3		2		2					2																																																																													2	2	1	6	Implant and abutment - one per 60 months per tooth. Re-cement implants - once per 24 months after 6 months of initial placement.	2				2				1	2	2	2	1	6	Pontics and retainers - one per 60 months per tooth.Fixed partial denture repair, - once every 24 months after 6 months of initial placement.	2				2				1	2																																													
H5926	009	0	1	01	01	H5926_009_0	8	2				1	20	20	20	2				2		2	2																																																																																																																		1	2		4000.00	3		2		2					2																																																																													2	2	1	6	Implant and abutment - one per 60 months per tooth. Re-cement implants - once per 24 months after 6 months of initial placement.	2				2				1	2	2	2	1	6	Pontics and retainers - one per 60 months per tooth.Fixed partial denture repair, - once every 24 months after 6 months of initial placement.	2				2				2	2																																													
H5928	004	0	1	01	01	H5928_004_0	7	2				2				2				2		2	1	2							2				2					2					2		2	1				2				2				2	2	2	2	1	6	Periodicity range: No frequency limit for panoramic radiographic image, bitewings  4 radiographic images limited to 1 series every 6 months, intraoral  comprehensive series of radiographic images limited to 1 series every 24 months.	2				3		0.00	5.00	2	2	2	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), assessment of salivary flow by measurement limited to 1 every 12 months.	2				3		0.00	8.00	2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				1	5.00	5.00	5.00	2	2	2	1				2				2				2	2	2								2					2		2	1				2				3		0.00	300.00	1	1	2	1				2				3		15.00	475.00	1	1	2	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	375.00	1	1	2	1				2				3		15.00	500.00	1	1																															2	1				2				3		45.00	570.00	1	1	2	1				2				3		0.00	150.00	1	1	2	1				2				3		0.00	350.00	1	1	2	1				2				3		0.00	105.00	2	2
H5928	010	0	1	01	01	H5928_010_0	7	2				2				3		0.00	30.00	2		2	1	2							2				2					2					2		2	1				2				2				2	2	2	2	1	6	Periodicity range: No frequency limit for panoramic radiographic image, bitewings  4 radiographic images limited to 1 series every 6 months, intraoral  comprehensive series of radiographic images limited to 1 series every 24 months.	2				3		0.00	5.00	2	2	2	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), assessment of salivary flow by measurement limited to 1 every 12 months.	2				3		0.00	8.00	2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				1	5.00	5.00	5.00	2	2	2	1				2				2				2	2	2								2					2		2	1				2				3		0.00	300.00	1	1	2	1				2				3		15.00	475.00	1	1	2	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	375.00	1	1	2	1				2				3		15.00	500.00	1	1																															2	1				2				3		45.00	570.00	1	1	2	1				2				3		0.00	150.00	1	1	2	1				2				3		0.00	350.00	1	1	2	1				2				3		0.00	105.00	2	2
H5932	001	0	1	01	01	H5932_001_0	10	2				1	24	24	24	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	1							2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 2 per year, 1 crown in 5 years per tooth.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																																														2	1				2				2				2	2																														
H5932	009	0	1	01	01	H5932_009_0	10	2				2				3		35.00	300.00	2		1	2	2							2				2					2					2		2	2	1	4		2				1	10.00	10.00	10.00	2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	2		2000.00	3		2		2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 1 per year, 1 crown in 5 years per tooth.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Dentures are covered one per arch every 5 years, including a full denture, a partial denture or an immediate denture and are not applied to the comprehensive maximum plan coverage amount.	1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																														
H5932	012	0	1	01	01	H5932_012_0	10	2				1	24	24	24	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	1							2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 2 per year, 1 crown in 5 years per tooth.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																																														2	1				2				2				2	2																														
H5932	013	0	1	01	01	H5932_013_0	9	2				2				3		35.00	300.00	2		1	2	2							2				2					2					2		2	2	1	4		2				1	10.00	10.00	10.00	2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	2		2000.00	3		2		2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 1 per year, 1 crown in 5 years per tooth.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Dentures are covered one per arch every 5 years, including a full denture, a partial denture or an immediate denture and are not applied to the comprehensive maximum plan coverage amount.	1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																														
H5934	001	0	1	20	08	H5934_001_0	1																																																																																																																																																																																																																																																																																																						
H5934	002	0	1	20	08	H5934_002_0	1																																																																																																																																																																																																																																																																																																						
H5938	001	0	1	01	01	H5938_001_0	6	2				2				1	45.00	45.00	45.00	2		1	1	1		625.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5938	006	0	1	01	01	H5938_006_0	6	2				2				1	35.00	35.00	35.00	2		1	1	1		725.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5938	008	0	1	01	01	H5938_008_0	6	2				2				1	50.00	50.00	50.00	2		1	1	1		525.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5938	009	0	1	01	01	H5938_009_0	6	2				2				1	60.00	60.00	60.00	2		1	1																																																																																																																																																																																																																																																																																						
H5938	802	0	1	01	01	H5938_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5938	803	0	1	01	01	H5938_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5938	804	0	1	01	01	H5938_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5938	805	0	1	01	01	H5938_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5943	003	0	1	02	01	H5943_003_0	11	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5943	005	0	1	02	01	H5943_005_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1500.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H5945	001	0	1	01	01	H5945_001_0	7	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H5945	002	0	1	01	01	H5945_002_0	7	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H5945	013	0	1	01	01	H5945_013_0	7	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H5945	014	0	1	01	01	H5945_014_0	7	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H5945	016	0	1	01	01	H5945_016_0	7	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H5945	017	0	1	01	01	H5945_017_0	6	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 0% coinsurance for full mouth debridement.  All other covered codes at 0% coinsurance at 1 per site/quad every 2 calendar years.	2				2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	2				2				2	2																															2	2	1	6	Once per arch per 5 years	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5945	018	0	1	01	01	H5945_018_0	6	2				2				2				2		2	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 0% coinsurance for full mouth debridement.  All other covered codes at 0% coinsurance at 1 per site/quad every 2 calendar years.	2				2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	2				2				2	2																															2	2	1	6	Once per arch per 5 years	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5945	027	0	1	01	01	H5945_027_0	7	2				2				2				2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H5945	032	0	1	01	01	H5945_032_0	5	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H5945	035	0	1	01	01	H5945_035_0	6	2				2				2				1	500.00	2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																					
H5945	036	0	1	02	01	H5945_036_0	4	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5945	801	0	1	01	01	H5945_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5945	802	0	1	01	01	H5945_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5945	804	0	1	01	01	H5945_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5945	805	0	1	01	01	H5945_805_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5959	018	0	1	04	01	H5959_018_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2																															1	1							2					2		2	1				1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2	2	1				3		0	20	2				1	2	2	1				1	20	20	20	2				1	2																															2	1				1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																2	1				3		0	20	2				1	2
H5959	019	0	1	04	01	H5959_019_0	9	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2																															1	1							2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H5959	020	0	1	04	01	H5959_020_0	8	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2																															1	1							2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H5959	021	0	1	04	01	H5959_021_0	8	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	2 routine ORAL EVAL per calendar year 1 COMPREHENSIVE PERIODONTAL EVAL per 3 years 1 DETAILED AND EXTENSIVE ORAL EVAL per 12 months,1 COMBINATION CONSULTATION AND A LIMITED oral eval per 12 months	2				2				1	2	2	2	1	6	4 BITEWING RADIOGRAPH  calendar year, or ONE FULL MOUTH RADIOGRAPH SERIES or INTRAORAL TOMOSYNTHESIS calendar year, or 4 PERIAPICAL IMAGES per 12 months, or one COMPREHENSIVE SERIES per 5 years	2				2				1	2																2	2	2	3		2				2				1	2																															1	1							2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H5959	023	1	1	04	01	H5959_023_1	8	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2																															1	1							2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H5959	023	2	1	04	01	H5959_023_2	7	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3				2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2																															1	1							2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H5959	024	0	1	04	01	H5959_024_0	8	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2																															1	1							2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H5959	801	0	1	04	01	H5959_801_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5959	807	0	1	04	01	H5959_807_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5959	808	0	1	04	01	H5959_808_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5959	809	0	1	04	01	H5959_809_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5959	810	0	1	04	01	H5959_810_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H5969	002	0	1	01	01	H5969_002_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H5970	016	0	1	04	01	H5970_016_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5970	028	0	1	04	01	H5970_028_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H5970	029	0	1	04	01	H5970_029_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H5970	801	0	1	04	01	H5970_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5970	802	0	1	04	01	H5970_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5970	805	0	2	04	01	H5970_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5970	806	0	2	04	01	H5970_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5970	816	0	1	04	01	H5970_816_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5970	817	0	1	04	01	H5970_817_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5970	818	0	1	04	01	H5970_818_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5970	819	0	1	04	01	H5970_819_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5970	822	0	1	04	01	H5970_822_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5970	823	0	1	04	01	H5970_823_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5970	828	0	1	04	01	H5970_828_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5970	829	0	1	04	01	H5970_829_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H5978	001	0	1	20	08	H5978_001_0	1																																																																																																																																																																																																																																																																																																						
H5978	002	0	1	20	08	H5978_002_0	1																																																																																																																																																																																																																																																																																																						
H5989	011	0	1	01	01	H5989_011_0	10	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2
H5991	014	0	1	01	01	H5991_014_0	9	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H5992	007	0	1	01	01	H5992_007_0	7	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	6	1 periodic oral evaluation per 6 months.1 comprehensive oral evaluation per lifetime per provider/location.1 extensive oral evaluation problem focused per 90 days	2				2				2	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	1 of screening or assessment of a patient per 10 days1 of diagnostic casts per 12 months by oral surgeon for physically handicapping malocclusion	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	6	1 of topical application of fluoride varnish per 3 months, 4 per 12 months1 of topical application of fluoride-excluding varnish per 6 months	2				2				2	2	2	2	1	6	2 of application of caries arresting medicament per 12 months, same toothtotal of 4 per lifetime per patient, same tooth	2				2				1	2	2								2					2		2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	1 per lifetime same tooth:pulpotomy, pulpal therapy, root canals, retreatment of root canals, apicoectomy, retrograde filling	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	fixed dentures and associated services-1 per 60 monthsrecement or re-bond fixed dentures-1 per 24 months per quadrantfixed denture repair-1 per 60 months same quadrant	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2																2	2	1	6	Palliative treatment-two per 12 monthsConsultations-1 per 6 monthshospital or ambulatory surgical center-3 per weekoffice visit for observation-4 per 12 monthsocclusal guard-1 per 12 months	2				2				1	2
H5992	010	0	1	01	01	H5992_010_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	6	1 periodic oral evaluation per 6 months.1 comprehensive oral evaluation per lifetime per provider/location.1 extensive oral evaluation problem focused per 90 days	2				2				2	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	1 of screening or assessment of a patient per 10 days1 of diagnostic casts per 12 months by oral surgeon for physically handicapping malocclusion	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	6	1 of topical application of fluoride varnish per 3 months, 4 per 12 months1 of topical application of fluoride-excluding varnish per 6 months	2				2				2	2	2	2	1	6	2 of application of caries arresting medicament per 12 months, same toothtotal of 4 per lifetime per patient, same tooth	2				2				1	2	2								2					2		2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	1 per lifetime same tooth:pulpotomy, pulpal therapy, root canals, retreatment of root canals, apicoectomy, retrograde filling	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	fixed dentures and associated services-1 per 60 monthsrecement or re-bond fixed dentures-1 per 24 months per quadrantfixed denture repair-1 per 60 months same quadrant	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2																2	2	1	6	Palliative treatment-two per 12 monthsConsultations-1 per 6 monthshospital or ambulatory surgical center-3 per weekoffice visit for observation-4 per 12 monthsocclusal guard-1 per 12 months	2				2				1	2
H5993	001	0	1	20	08	H5993_001_0	1																																																																																																																																																																																																																																																																																																						
H5993	002	0	1	20	08	H5993_002_0	1																																																																																																																																																																																																																																																																																																						
H6018	003	0	1	04	01	H6018_003_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6018	007	0	1	04	01	H6018_007_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6018	008	0	1	04	01	H6018_008_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6018	010	0	1	04	01	H6018_010_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6018	011	0	1	04	01	H6018_011_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6019	001	0	1	01	01	H6019_001_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6059	001	0	1	20	08	H6059_001_0	1																																																																																																																																																																																																																																																																																																						
H6059	002	0	1	20	08	H6059_002_0	1																																																																																																																																																																																																																																																																																																						
H6078	801	0	1	04	01	H6078_801_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H6078	802	0	1	04	01	H6078_802_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H6079	001	0	1	20	08	H6079_001_0	1																																																																																																																																																																																																																																																																																																						
H6079	002	0	1	20	08	H6079_002_0	1																																																																																																																																																																																																																																																																																																						
H6081	001	0	1	20	08	H6081_001_0	1																																																																																																																																																																																																																																																																																																						
H6081	002	0	1	20	08	H6081_002_0	1																																																																																																																																																																																																																																																																																																						
H6130	801	0		07	02	H6130_801_0	1																																																																																																																																																																																																																																																																																																						
H6130	802	0		07	02	H6130_802_0	1																																																																																																																																																																																																																																																																																																						
H6130	803	0		07	02	H6130_803_0	1																																																																																																																																																																																																																																																																																																						
H6130	804	0		07	02	H6130_804_0	1																																																																																																																																																																																																																																																																																																						
H6130	805	0		07	02	H6130_805_0	1																																																																																																																																																																																																																																																																																																						
H6130	806	0		07	02	H6130_806_0	1																																																																																																																																																																																																																																																																																																						
H6130	807	0		07	02	H6130_807_0	1																																																																																																																																																																																																																																																																																																						
H6130	808	0		07	02	H6130_808_0	1																																																																																																																																																																																																																																																																																																						
H6130	809	0		07	02	H6130_809_0	1																																																																																																																																																																																																																																																																																																						
H6130	810	0		07	02	H6130_810_0	1																																																																																																																																																																																																																																																																																																						
H6130	811	0		07	02	H6130_811_0	1																																																																																																																																																																																																																																																																																																						
H6130	812	0		07	02	H6130_812_0	1																																																																																																																																																																																																																																																																																																						
H6130	813	0		07	02	H6130_813_0	1																																																																																																																																																																																																																																																																																																						
H6130	814	0		07	02	H6130_814_0	1																																																																																																																																																																																																																																																																																																						
H6130	815	0		07	02	H6130_815_0	1																																																																																																																																																																																																																																																																																																						
H6130	816	0		07	02	H6130_816_0	1																																																																																																																																																																																																																																																																																																						
H6130	817	0		07	02	H6130_817_0	1																																																																																																																																																																																																																																																																																																						
H6130	818	0		07	02	H6130_818_0	1																																																																																																																																																																																																																																																																																																						
H6147	001	0	1	20	08	H6147_001_0	1																																																																																																																																																																																																																																																																																																						
H6147	002	0	1	20	08	H6147_002_0	1																																																																																																																																																																																																																																																																																																						
H6158	001	0	1	01	01	H6158_001_0	3	2				2				1	45.00	45.00	45.00	2		2	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	2		3000.00	3		2		2					2		2	2	1	3		1	20	20	20	2				2	2																2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2				2	2	2	2	2	6	Periodicities for covered services range from every year to every five years depending on the service.	1	20	20	20	2				2	2																																														2	1				1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H6170	001	0	1	02	01	H6170_001_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	002	0	1	02	01	H6170_002_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	007	0	1	01	01	H6170_007_0	10	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	008	0	1	01	01	H6170_008_0	9	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	009	0	1	01	01	H6170_009_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	010	0	1	01	01	H6170_010_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	015	0	1	01	01	H6170_015_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	016	0	1	01	01	H6170_016_0	9	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	017	0	1	01	01	H6170_017_0	10	2				2				2				2		2	2	1		2600.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	018	0	1	01	01	H6170_018_0	10	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6188	001	0	1	20	08	H6188_001_0	1																																																																																																																																																																																																																																																																																																						
H6188	002	0	1	20	08	H6188_002_0	1																																																																																																																																																																																																																																																																																																						
H6194	001	0	1	01	01	H6194_001_0	6	2				2				1	25.00	25.00	25.00	2		2	2	1		650.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																																																												2	1				2				2				2	2
H6194	002	0	1	01	01	H6194_002_0	6	2				2				1	25.00	25.00	25.00	2		2	2	1		200.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2																																																																																																																																							
H6200	001	0	1	04	01	H6200_001_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	825.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6200	004	0	1	04	01	H6200_004_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	400.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6200	006	0	1	04	01	H6200_006_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1	2	475.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6200	008	0	1	04	01	H6200_008_0	6	2				2				2				2		1	2																																																																																																																																																																																																																																																																																						
H6200	009	0	1	04	01	H6200_009_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	650.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6200	010	0	1	04	01	H6200_010_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1900.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6200	011	0	1	04	01	H6200_011_0	6	2				2				2				2		1	2																																																																																																																																																																																																																																																																																						
H6200	801	0	1	04	01	H6200_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H6200	802	0	1	04	01	H6200_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H6200	803	0	1	04	01	H6200_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H6200	804	0	1	04	01	H6200_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H6224	001	0	1	01	01	H6224_001_0	10	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	1							2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 2 per year, 1 crown in 5 years per tooth.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																																														2	1				2				2				2	2																														
H6231	001	0	1	20	08	H6231_001_0	2																																																																																																																																																																																																																																																																																																						
H6231	002	0	1	20	08	H6231_002_0	2																																																																																																																																																																																																																																																																																																						
H6237	009	0	1	01	01	H6237_009_0	10	2				2				1	45.00	45.00	45.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement, limit is combined with prophylaxis.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year.	1	50	50	50	2				2	2																														
H6248	001	0	1	01	01	H6248_001_0	8	2				2				2				2		2	1	2							2				2					2					2		2	2	2	3		2				2				2	1	2	2	2	3		2				2				2	1																2	2	2	3		2				2				2	1	2	2	2	3		2				2				2	1																1	2		2000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	1	2	1				2				2				2	2	2	1				2				2				2	1	2	1				2				2				2	1	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6251	001	0	1	20	08	H6251_001_0	1																																																																																																																																																																																																																																																																																																						
H6251	002	0	1	20	08	H6251_002_0	1																																																																																																																																																																																																																																																																																																						
H6303	001	0	1	02	01	H6303_001_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H6303	002	0	1	02	01	H6303_002_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H6303	004	0	1	02	01	H6303_004_0	3	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H6303	005	0	1	02	01	H6303_005_0	3	2				1	30	30	30	2				2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H6309	001	0	1	04	01	H6309_001_0	6	2				2				1	55.00	55.00	55.00	2		2	2	2							2				2					2					2		2	2	1	3		1	25	25	25	2				2	2	2	2	1	3		1	25	25	25	2				2	2																2	2	1	3		1	25	25	25	2				2	2																2	2	1	1		1	25	25	25	2				2	2	2								2					2																																2	2	1	3		1	25	25	25	2				2	2																																																																																																									
H6309	002	0	1	04	01	H6309_002_0	5	2				2				1	60.00	60.00	60.00	2		2	2																																																																																																																																																																																																																																																																																						
H6309	801	0	1	04	01	H6309_801_0	1	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6309	802	0	1	04	01	H6309_802_0	1	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6316	007	1	1	01	01	H6316_007_1	4	2				1	20	20	20	2				2		1	2	1		3500.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H6316	007	2	1	01	01	H6316_007_2	4	2				1	20	20	20	2				2		1	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H6317	001	0	1	20	08	H6317_001_0	1																																																																																																																																																																																																																																																																																																						
H6317	002	0	1	20	08	H6317_002_0	1																																																																																																																																																																																																																																																																																																						
H6322	001	0	1	01	01	H6322_001_0	6	2				2				3		40.00	45.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				1	50	50	50	2				2	2	3													2	2	4	2	2	6	See notes	3		0	50	2				2	2	3													2	2																3													2	2	3													2	2	4	1				3		0	50	2				2	2																4	1				2				2				2	2
H6322	002	0	1	01	01	H6322_002_0	7	2				2				1	35.00	35.00	35.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				1	50	50	50	2				2	2	3													2	2	4	2	2	6	See notes	3		0	50	2				2	2	3													2	2																3													2	2	3													2	2	4	1				3		0	50	2				2	2																4	1				2				2				2	2
H6322	008	0	1	01	01	H6322_008_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				1	50	50	50	2				2	2	3													2	2	4	2	2	6	See notes	3		0	50	2				2	2	3													2	2																3													2	2	3													2	2	4	1				3		0	50	2				2	2																4	1				2				2				2	2
H6341	001	0	1	01	01	H6341_001_0	6	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Pre and post-op radiographs required. Prior authorization required. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 months. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H6341	002	0	1	01	01	H6341_002_0	5	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Pre and post-op radiographs required. Prior authorization required. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 months. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H6342	001	0	1	20	08	H6342_001_0	1																																																																																																																																																																																																																																																																																																						
H6342	002	0	1	20	08	H6342_002_0	1																																																																																																																																																																																																																																																																																																						
H6345	001	0	1	01	01	H6345_001_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H6345	002	0	1	01	01	H6345_002_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H6345	003	0	1	01	01	H6345_003_0	4	2				2				2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the notes for periodicity.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H6348	002	0	1	04	01	H6348_002_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H6348	008	0	1	04	01	H6348_008_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1500.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	1	20	20	20	2				1	2	2	2	1	6	Once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	Every 6 months to 2 years	1	20	20	20	2				1	2	2	2	1	6	Every year to 5 years	1	20	20	20	2				1	2																																														2	2	1	6	Per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	Every date of service to every 5 years	1	20	20	20	2				1	2
H6351	001	0	1	01	01	H6351_001_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6351	004	0	1	01	01	H6351_004_0	4	2				1	20	20	20	2				2		2	2	1		3000.00	3		1	2	2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H6351	005	0	1	01	01	H6351_005_0	5	2				1	20	20	20	2				2		2	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	2		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H6368	001	0	1	01	01	H6368_001_0	6	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Various periodicity based on the dental code. Please see the note below.	2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	2	6	Various periodicity based on the dental code. Please see the note below.	2				2				1	1	2	2	2	6	Various periodicity based on the dental code. Please see the note below.	2				2				2	2	2	2	1	6	Various periodicity based on the dental code. Please see the note below.	2				2				1	1																																																													2	2	3	3		2				2				1	1																2	2	3	6	Various periodicity based on the dental code. Please see the note below.	2				2				1	1
H6368	002	0	1	01	01	H6368_002_0	6	2				2				2				2		2	2	1		600.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Various periodicity based on the dental code. Please see the note below.	2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	2	6	Various periodicity based on the dental code. Please see the note below.	2				2				1	1	2	2	2	6	Various periodicity based on the dental code. Please see the note below.	2				2				2	2	2	2	2	6	Various periodicity based on the dental code. Please see the note below.	2				2				1	1																																																													2	2	3	6	Various periodicity based on the dental code. Please see the note below.	2				2				1	1																2	2	2	6	Various periodicity based on the dental code. Please see the note below.	2				2				1	1
H6371	001	0	1	20	08	H6371_001_0	1																																																																																																																																																																																																																																																																																																						
H6371	002	0	1	20	08	H6371_002_0	1																																																																																																																																																																																																																																																																																																						
H6378	001	0	1	01	01	H6378_001_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		1500.00	3		2		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Pre and post-op radiographs required. Prior authorization required. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 months. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H6378	002	0	1	01	01	H6378_002_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		2000.00	3		2		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Pre and post-op radiographs required. Prior authorization required. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 months. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H6396	017	0	1	01	01	H6396_017_0	6	2				1	20	20	20	2				2		1	2	1		300.00	7		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6399	001	0	1	01	01	H6399_001_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H6407	002	0	1	01	01	H6407_002_0	9	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	1	6	Subject to limitations described in the note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1000.00	3		2		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	50	50	50	2				2	2																															2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6407	801	0	1	01	01	H6407_801_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6425	001	0	1	20	08	H6425_001_0	1																																																																																																																																																																																																																																																																																																						
H6425	002	0	1	20	08	H6425_002_0	1																																																																																																																																																																																																																																																																																																						
H6453	013	1	1	02	01	H6453_013_1	8	2				2				1	0.00	0.00	0.00	2		2	2	1		2200.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	013	3	1	02	01	H6453_013_3	8	2				2				1	0.00	0.00	0.00	2		2	2	1		2200.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	013	4	1	02	01	H6453_013_4	9	2				2				1	0.00	0.00	0.00	2		2	2	1		2200.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	017	1	1	02	01	H6453_017_1	9	2				2				1	0.00	0.00	0.00	2		2	2	1		1000.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	017	2	1	02	01	H6453_017_2	9	2				2				1	0.00	0.00	0.00	2		2	2	1		1000.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	018	1	1	02	01	H6453_018_1	8	2				2				1	0.00	0.00	0.00	2		2	2	1		2700.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	018	2	1	02	01	H6453_018_2	10	2				2				1	0.00	0.00	0.00	2		2	2	1		2700.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	019	0	1	02	01	H6453_019_0	9	2				1	20	20	20	2				2		2	2	1		2700.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	021	0	1	02	01	H6453_021_0	8	2				2				1	0.00	0.00	0.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	801	0	1	01	01	H6453_801_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6453	802	0	1	01	01	H6453_802_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6453	803	0	1	01	01	H6453_803_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6453	804	0	1	02	01	H6453_804_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6474	001	0	1	02	01	H6474_001_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6474	002	0	1	02	01	H6474_002_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6474	007	0	1	01	01	H6474_007_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6474	008	0	1	01	01	H6474_008_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6474	009	0	1	01	01	H6474_009_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6474	010	0	1	01	01	H6474_010_0	8	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6515	001	0	1	01	01	H6515_001_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H6515	002	0	1	01	01	H6515_002_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H6515	003	0	1	01	01	H6515_003_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H6515	004	0	1	01	01	H6515_004_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		500.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H6515	005	0	1	01	01	H6515_005_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H6517	001	0	1	20	08	H6517_001_0	3																																																																																																																																																																																																																																																																																																						
H6517	002	0	1	20	08	H6517_002_0	3																																																																																																																																																																																																																																																																																																						
H6529	004	0	1	01	01	H6529_004_0	9	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Cast restorations (including crowns and onlays) and associated procedures (such as cores and substructures) on the same tooth are payable once in any five-year period. Posterior composite resin restorations are covered services.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	6	Every year for periodic maintenance, but note that root planing and scaling is payable once per quadrant in 24 consecutive months. Full mouth debridement is a benefit once in a lifetime.	3		0	50	2				2	2	2	2	1	6	Full and partial dentures are limited to once in a five year period. Relines and Rebase to existing Full and Partial Dentures covered once every 36 months	1	50	50	50	2				2	2																2	2	1	6	1 implant per tooth per 5 year period.	1	50	50	50	2				2	2	2	2	1	6	Bridges are covered once in a 5-year period. Relines & repairs to bridges covered once per tooth per 5-year period.	1	50	50	50	2				2	2	2	2	1	6	1 extraction per tooth per lifetime.	1	50	50	50	2				2	2																2	1				3		0	50	2				2	2
H6537	001	0	1	20	08	H6537_001_0	1																																																																																																																																																																																																																																																																																																						
H6537	002	0	1	20	08	H6537_002_0	1																																																																																																																																																																																																																																																																																																						
H6541	001	0	1	20	08	H6541_001_0	1																																																																																																																																																																																																																																																																																																						
H6541	002	0	1	20	08	H6541_002_0	1																																																																																																																																																																																																																																																																																																						
H6545	001	0	1	04	01	H6545_001_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6545	010	0	1	04	01	H6545_010_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6550	003	0	1	02	01	H6550_003_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H6550	004	0	1	02	01	H6550_004_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H6550	009	0	1	02	01	H6550_009_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth Every 7 plan years. Other restorative Every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per plan year, and once per same tooth Every 7 plan years; other implant services Every year to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth Every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H6551	001	0	1	20	08	H6551_001_0	1																																																																																																																																																																																																																																																																																																						
H6551	002	0	1	20	08	H6551_002_0	1																																																																																																																																																																																																																																																																																																						
H6566	001	0	1	04	01	H6566_001_0	8	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2
H6585	001	0	1	01	01	H6585_001_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		6000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H6585	002	0	1	01	01	H6585_002_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H6586	001	0	1	04	01	H6586_001_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6586	002	0	1	04	01	H6586_002_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6586	003	0	1	04	01	H6586_003_0	7	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6586	005	0	1	04	01	H6586_005_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6586	006	0	1	04	01	H6586_006_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6595	003	0	1	02	01	H6595_003_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H6595	006	1	1	02	01	H6595_006_1	4	2				1	20	20	20	2				2		1	2	1		2500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H6595	006	2	1	02	01	H6595_006_2	4	2				1	20	20	20	2				2		1	2	1		2000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H6595	007	1	1	02	01	H6595_007_1	4	2				1	20	20	20	2				2		1	2	1		1500.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H6595	007	2	1	02	01	H6595_007_2	4	2				1	20	20	20	2				2		1	2	1		1000.00	3				2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H6596	001	0	1	20	08	H6596_001_0	5																																																																																																																																																																																																																																																																																																						
H6596	002	0	1	20	08	H6596_002_0	5																																																																																																																																																																																																																																																																																																						
H6622	001	0	1	01	01	H6622_001_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H6622	004	0	1	01	01	H6622_004_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	007	0	1	01	01	H6622_007_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H6622	008	0	1	01	01	H6622_008_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	013	0	1	02	01	H6622_013_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H6622	014	0	1	02	01	H6622_014_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	017	0	1	01	01	H6622_017_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		500.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H6622	018	0	1	01	01	H6622_018_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	021	1	1	02	01	H6622_021_1	4	2				2				1	45.00	45.00	45.00	2		1	2	1		750.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	021	2	1	02	01	H6622_021_2	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H6622	022	0	1	02	01	H6622_022_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H6622	023	0	1	02	01	H6622_023_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	025	0	1	02	01	H6622_025_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	026	0	1	02	01	H6622_026_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	027	0	1	02	01	H6622_027_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	028	0	1	01	01	H6622_028_0	4	2				2				1	10.00	10.00	10.00	2		1	1	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	1	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H6622	029	0	1	01	01	H6622_029_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H6622	032	0	1	01	01	H6622_032_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	033	0	1	01	01	H6622_033_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H6622	035	0	1	01	01	H6622_035_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H6622	036	0	1	01	01	H6622_036_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H6622	037	0	1	01	01	H6622_037_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	047	0	1	01	01	H6622_047_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	048	0	1	01	01	H6622_048_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	054	0	1	01	01	H6622_054_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	055	0	1	01	01	H6622_055_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H6622	056	0	1	01	01	H6622_056_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	1
H6622	057	0	1	02	01	H6622_057_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	060	0	1	02	01	H6622_060_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	061	0	1	02	01	H6622_061_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	071	0	1	01	01	H6622_071_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	075	0	1	01	01	H6622_075_0	6	2				2				1	30.00	30.00	30.00	2		1	1	1		1500.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	3	2		2				1	25.00	25.00	25.00	1	1	3													2	2	4	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				3		0.00	25.00	1	1	3													2	2																															3													2	2	3													2	2																4	2	1	6	1 unit/visit	2				1	0.00	0.00	0.00	1	1
H6622	078	1	1	01	01	H6622_078_1	4	2				1	20	20	20	2				2		1	2	1		3000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	078	2	1	01	01	H6622_078_2	4	2				1	20	20	20	2				2		1	2	1		5000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	079	0	1	01	01	H6622_079_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H6622	081	0	1	01	01	H6622_081_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H6622	082	0	1	01	01	H6622_082_0	4	2				2				1	25.00	25.00	25.00	2		1	1	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	1
H6622	083	0	1	01	01	H6622_083_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	084	0	1	01	01	H6622_084_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H6622	085	0	1	01	01	H6622_085_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	090	0	1	01	01	H6622_090_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H6622	091	0	1	01	01	H6622_091_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	094	0	1	01	01	H6622_094_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	0.00	0.00	0.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H6622	097	0	1	01	01	H6622_097_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		1250.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H6622	098	0	1	01	01	H6622_098_0	6	2				2				1	25.00	25.00	25.00	2		1	1	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	1	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	1
H6622	099	1	1	01	01	H6622_099_1	4	2				2				1	55.00	55.00	55.00	2		1	2	1		1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	099	2	1	01	01	H6622_099_2	4	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	100	1	1	01	01	H6622_100_1	5	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H6622	100	2	1	01	01	H6622_100_2	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1500.00	3				2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H6622	101	0	1	01	01	H6622_101_0	4	2				1	20	20	20	2				2		1	1	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H6622	103	0	1	01	01	H6622_103_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	104	0	1	01	01	H6622_104_0	4	2				1	20	20	20	2				2		1	1	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H6622	105	0	1	01	01	H6622_105_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	801	0	1	01	01	H6622_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H6622	802	0	1	01	01	H6622_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H6622	804	0	1	01	01	H6622_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H6622	805	0	1	01	01	H6622_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H6652	001	0	1	01	01	H6652_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6697	001	0	1	01	01	H6697_001_0	9	2				2				2				2		1	2	1		300.00	5		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H6697	002	0	1	01	01	H6697_002_0	12	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																1	2		750.00	5		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H6697	003	0	1	01	01	H6697_003_0	11	2				2				2				2		1	2	2							2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																2								2					2		4	1				2				3		20.00	400.00	1	2	4	1				2				3		25.00	350.00	1	2	4	1				2				3		15.00	550.00	1	2	4	1				2				3		20.00	570.00	1	2																															4	1				2				3		40.00	400.00	1	2	4	1				2				3		25.00	250.00	1	2																														
H6697	004	0	1	01	01	H6697_004_0	10	2				2				2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H6697	005	0	1	01	01	H6697_005_0	10	2				2				2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H6697	801	0	1	01	01	H6697_801_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H6697	802	0	1	01	01	H6697_802_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H6697	803	0	1	01	01	H6697_803_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H6697	804	0	1	01	01	H6697_804_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H6700	001	0	1	20	08	H6700_001_0	1																																																																																																																																																																																																																																																																																																						
H6700	002	0	1	20	08	H6700_002_0	1																																																																																																																																																																																																																																																																																																						
H6706	001	0	1	02	01	H6706_001_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H6723	001	1	1	02	01	H6723_001_1	9	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				1	30	30	30	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																																																													4	1				1	30	30	30	2				2	2																4	1				1	30	30	30	2				2	2
H6723	001	3	1	02	01	H6723_001_3	6	2				2				1	35.00	35.00	35.00	2		1	2	1		850.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				1	30	30	30	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																																																													4	1				1	30	30	30	2				2	2																4	1				1	30	30	30	2				2	2
H6723	002	1	1	01	01	H6723_002_1	7	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																				
H6723	002	3	1	01	01	H6723_002_3	7	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																				
H6723	003	1	1	01	01	H6723_003_1	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				1	30	30	30	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																																																													4	1				1	30	30	30	2				2	2																4	1				1	30	30	30	2				2	2
H6723	003	3	1	01	01	H6723_003_3	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	1				1	30	30	30	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																																																													4	1				1	30	30	30	2				2	2																4	1				1	30	30	30	2				2	2
H6723	007	0	1	02	01	H6723_007_0	8	2				1	0	0	0	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				2				2	2	2	1				1	0	0	0	2				2	2	2	1				2				2				2	2																																																													2	1				2				2				2	2																2	1				2				2				2	2
H6723	008	0	1	02	01	H6723_008_0	8	2				1	0	0	0	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																																													2	1				2				2				2	2																2	1				2				2				2	2
H6723	009	0	1	02	01	H6723_009_0	8	2				1	0	0	0	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																																													2	1				2				2				2	2																2	1				2				2				2	2
H6723	801	0	1	01	01	H6723_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6723	802	0	1	01	01	H6723_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6723	803	0	1	01	01	H6723_803_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6743	001	0	1	04	01	H6743_001_0	6	2				2				1	45.00	45.00	45.00	2		2	2	1	2	200.00	4		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	007	0	1	04	01	H6743_007_0	5	2				2				1	45.00	45.00	45.00	2		2	2	1	2	300.00	5		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	025	0	1	04	01	H6743_025_0	5	2				2				1	45.00	45.00	45.00	2		2	2	1	2	300.00	4		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	026	0	1	04	01	H6743_026_0	7	2				2				1	25.00	25.00	25.00	2		2	2	1	2	300.00	4		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	027	0	1	04	01	H6743_027_0	2	2				2				1	45.00	45.00	45.00	2		2	2	1	2	400.00	4		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	028	0	1	04	01	H6743_028_0	5	2				2				1	35.00	35.00	35.00	2		2	2	1	2	500.00	4		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	029	0	1	04	01	H6743_029_0	2	2				2				1	45.00	45.00	45.00	2		2	2	1	2	400.00	4		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	030	0	1	04	01	H6743_030_0	5	2				2				1	15.00	15.00	15.00	2		2	2	1	2	300.00	4		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	031	0	1	04	01	H6743_031_0	2	2				2				1	45.00	45.00	45.00	2		2	2	1	2	300.00	4		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	801	0	1	04	01	H6743_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H6743	802	0	1	04	01	H6743_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H6743	803	0	1	04	01	H6743_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H6743	804	0	1	04	01	H6743_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H6759	001	0	1	20	08	H6759_001_0	1																																																																																																																																																																																																																																																																																																						
H6759	002	0	1	20	08	H6759_002_0	1																																																																																																																																																																																																																																																																																																						
H6765	001	0	1	01	01	H6765_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6765	002	0	1	01	01	H6765_002_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6765	003	0	1	01	01	H6765_003_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6776	001	0	1	01	01	H6776_001_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H6776	002	0	1	01	01	H6776_002_0	3	2				2				2				2		1	2	2							2				2					2					2		2	2	3	6	Periodic Oral evaluation 1 every 6 monthsLimited oral evaluation 2 every 12 months.Comprehensive oral evaluation 1 per provider in a lifetime.Oral evaluation, problem focused 3 every 12 months, by report.	2				2				2	2	2	2	1	6	Intraoral, complete series - 1 every 36 months.  Intraoral, periapical (D0220) - 3 every 6 months; Intraoral, periapical (D0230, D0240) 6 times every 12 months.Panoramic Radiographic image- 1 every 3 years.	2				2				2	2	2	2	1	6	Cone beam CT capture and interpretation - 1 every 60 months.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	6	Covered up to age of 20	2				2				2	2	2	2	1	6	Tobacco counseling, control prevention oral disease - 1 every 6 months.Unspecified preventive procedure, by report.	2				2				2	2	2								2					2		2	2	1	6	Amalgam / Resin based composite filling - 1 per tooth, per surface - every 24 months.Crown services - 1 per tooth - every 60 months.	2				2				1	2	2	2	1	6	Endodontic Services - 1 per tooth, per lifetime.	2				2				1	1	2	2	1	6	Gingivectomy/pIasty - 1 every 12 months, per quad. Crown lengthening 1 per tooth per lifetime. Periodontal scaIIng and root pIaning 1 every 24 months per site. Periodontal maintenance once every 6 mo.	2				2				1	1	2	2	1	6	Complete /Partial denture - 1 every 96 months, per arch.Denture Adjustment - 4 every 12 months, per arch (Not covered within 6 months of placement).	2				2				1	2	2	2	1	6	1 every 12 months	2				2				1	1	2	2	1	6	Surgical placement of implant - 1 per tooth, in a lifetime.Abutment services - 1 per tooth, every 96 months.Debridement services - 1 per tooth, every 24 months.	2				2				1	2	2	2	1	6	1 every 60 months, per tooth	2				2				1	2	2	2	1	6	Extraction of erupted or impacted tooth 1 per tooth, in a lifetime. Alveoloplasty once per site/quad in a lifetime.   Other Oral and Maxillofacial Surgery by report.	2				2				1	1																2	2	1	6	Palliative emergency treatment 2 every 12 months.  Deep sedation maximum of 60 minutes or 4 units	2				2				1	2
H6787	001	0	1	20	08	H6787_001_0	1																																																																																																																																																																																																																																																																																																						
H6787	002	0	1	20	08	H6787_002_0	1																																																																																																																																																																																																																																																																																																						
H6796	001	0	1	20	08	H6796_001_0	1																																																																																																																																																																																																																																																																																																						
H6796	002	0	1	20	08	H6796_002_0	1																																																																																																																																																																																																																																																																																																						
H6813	001	0	1	04	01	H6813_001_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6813	006	0	1	04	01	H6813_006_0	1	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6815	038	0	1	02	01	H6815_038_0	7	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H6815	040	0	1	02	01	H6815_040_0	8	2				2				3		15.00	45.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2		2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H6824	002	0	1	04	01	H6824_002_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H6824	003	0	1	04	01	H6824_003_0	5	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
H6832	001	0	1	01	01	H6832_001_0	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H6832	004	0	1	02	01	H6832_004_0	7	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3500.00	3		2		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H6846	001	0	1	20	08	H6846_001_0	1																																																																																																																																																																																																																																																																																																						
H6846	002	0	1	20	08	H6846_002_0	1																																																																																																																																																																																																																																																																																																						
H6847	001	0	1	02	01	H6847_001_0	9	2				2				1	45.00	45.00	45.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		800.00	3		2		2					2		2	2	1	6	Amalgam and resin fillings 1 per surface per tooth every calendar year Crowns-1 per tooth per 5 calendar years. Re-cementing inlay/onlay, crown, post and core-1 per tooth per calendar year.	2				2				1	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				1	2	2	2	1	6	Every 5 years	2				2				2	2																															2	2	1	3		2				2				2	2	2	1				2				2				1	2																2	2	2	3		2				2				1	2
H6847	002	0	1	02	01	H6847_002_0	7	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																				
H6847	003	0	1	02	01	H6847_003_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2		2					2		2	2	1	6	Amalgam and resin fillings 1 per surface per tooth every calendar year Crowns-1 per tooth per 5 calendar years. Re-cementing inlay/onlay, crown, post and core-1 per tooth per calendar year.	2				2				1	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				1	2	2	2	1	6	Every 5 years	2				2				2	2																															2	2	1	3		2				2				2	2	2	1				2				2				1	2																2	2	2	3		2				2				1	2
H6847	801	0	1	02	01	H6847_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6847	802	0	1	02	01	H6847_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6847	803	0	1	02	01	H6847_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H6852	005	0	1	01	01	H6852_005_0	5	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	007	0	1	01	01	H6852_007_0	5	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	008	0	1	01	01	H6852_008_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	009	0	1	01	01	H6852_009_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6852	010	0	1	01	01	H6852_010_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	011	0	1	01	01	H6852_011_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6852	012	0	1	01	01	H6852_012_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	013	0	1	01	01	H6852_013_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6852	014	0	1	01	01	H6852_014_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	015	0	1	01	01	H6852_015_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6852	016	0	1	01	01	H6852_016_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	017	0	1	01	01	H6852_017_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	018	0	1	01	01	H6852_018_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	019	0	1	01	01	H6852_019_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	020	0	1	01	01	H6852_020_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	021	0	1	01	01	H6852_021_0	5	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	022	0	1	01	01	H6852_022_0	5	2				1	30	30	30	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	023	0	1	01	01	H6852_023_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	025	0	1	01	01	H6852_025_0	5	2				1	30	30	30	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	026	0	1	01	01	H6852_026_0	5	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	027	0	1	01	01	H6852_027_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	028	0	1	01	01	H6852_028_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	029	0	1	01	01	H6852_029_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	030	0	1	01	01	H6852_030_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	031	0	1	01	01	H6852_031_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	032	0	1	01	01	H6852_032_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	033	0	1	01	01	H6852_033_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	034	0	1	01	01	H6852_034_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	035	0	1	01	01	H6852_035_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6852	036	0	1	01	01	H6852_036_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6868	001	0	1	20	08	H6868_001_0	5																																																																																																																																																																																																																																																																																																						
H6868	002	0	1	20	08	H6868_002_0	5																																																																																																																																																																																																																																																																																																						
H6876	001	0	1	04	01	H6876_001_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6876	003	0	1	04	01	H6876_003_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6876	004	0	1	04	01	H6876_004_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6876	005	0	1	04	01	H6876_005_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6876	007	0	1	04	01	H6876_007_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6876	009	0	1	04	01	H6876_009_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6887	001	0	1	20	08	H6887_001_0	1																																																																																																																																																																																																																																																																																																						
H6887	002	0	1	20	08	H6887_002_0	1																																																																																																																																																																																																																																																																																																						
H6941	001	0	1	20	08	H6941_001_0	1																																																																																																																																																																																																																																																																																																						
H6941	002	0	1	20	08	H6941_002_0	1																																																																																																																																																																																																																																																																																																						
H6958	001	0	1	20	08	H6958_001_0	1																																																																																																																																																																																																																																																																																																						
H6958	002	0	1	20	08	H6958_002_0	1																																																																																																																																																																																																																																																																																																						
H6959	001	0	1	01	01	H6959_001_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H6959	002	0	1	01	01	H6959_002_0	7	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2
H6971	001	0	1	01	01	H6971_001_0	7	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per date of service	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	6	6	Per lifetime	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every date of service to 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 24 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 12 to 60 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per date of service	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to 6 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to 12 months	2				1	0.00	0.00	0.00	1	2
H6988	004	0	1	01	01	H6988_004_0	5	2				1	20	20	20	2				2		1	1	2							2				2					2					2		2	2	3	6	For limited, Periodic and ComprehensiveLimited oral evaluation: 2 every 12 monthsComprehensive oral evaluation: 1 per lifetimeOral evaluation, problem focused: 3 every 12 months, by reportPeriodic Oral evaluation: 1 every 6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral, complete series: 1 every 36 monthsIntraoral, periapical: 3 every 6 monthsIntraoral, periapical: 6 times every 12 monthsPanoramic Radiographic image: 1 every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Cone beam CT capture and interpretation: 1 every 60 months	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	With varnish: 1 every 3 monthsExcluding varnish: 1 every 6 months Only covered for members under 21 or special approval due to salivary gland damage from surgery, radiation, or disease	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Tobacco counseling, control prevention oral disease: 1 every six monthsUnspecified preventive procedure, by report	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Amalgam / Resin based composites: 1 per tooth, every 24 monthsCrown services: 1 per tooth, every 60 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic Services: 1 per tooth, per lifetime	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Gingivectomy or gingivopIasty: 1 every 12 months, per quadCrown lengthening: 1 per tooth per lifetimePeriodontal scaling and root planning: 1 every 24 months per site/quadOther Periodontics: every 6 to 36 months	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Complete /Partial denture: 1 every 96 months, per archDenture Adjustment: 4 every 12 months, per arch	2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	6	Implants: once per tooth per lifetimeImplant scaling repair: once per 12 monthsImplant replacements/rebond/debridement: once per tooth 24 monthsImplant abutments: once per tooth per 96 monthsAll implant services require prior authorization	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics -Once every 60 months, per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	1 per tooth per lifetimeOther Oral and Maxillofacial Surgery by report	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Limited to members who exhibit a sever physically handicapping malocclusion	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Office visit, observation: 4 every 12 monthsOcclusal guard: 1 every 12 months	2				1	0.00	0.00	0.00	1	2
H6988	006	0	1	02	01	H6988_006_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H6988	007	0	1	02	01	H6988_007_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H6988	008	0	1	02	01	H6988_008_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H6988	009	0	1	02	01	H6988_009_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H6988	010	0	1	02	01	H6988_010_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every 5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H6994	001	0	1	01	01	H6994_001_0	7	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6994	002	0	1	01	01	H6994_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6994	003	0	1	01	01	H6994_003_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6994	004	0	1	01	01	H6994_004_0	5	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6994	008	0	1	01	01	H6994_008_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6994	009	0	1	01	01	H6994_009_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6994	010	0	1	01	01	H6994_010_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6994	011	0	1	01	01	H6994_011_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6994	012	0	1	01	01	H6994_012_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H6994	013	0	1	01	01	H6994_013_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6994	026	0	1	01	01	H6994_026_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6994	027	0	1	01	01	H6994_027_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6994	028	0	1	01	01	H6994_028_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6994	029	0	1	01	01	H6994_029_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6994	031	0	1	01	01	H6994_031_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H6994	032	0	1	01	01	H6994_032_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7003	001	0	1	20	08	H7003_001_0	1																																																																																																																																																																																																																																																																																																						
H7003	002	0	1	20	08	H7003_002_0	1																																																																																																																																																																																																																																																																																																						
H7006	007	0	1	04	01	H7006_007_0	5	2				2				2				2		2	2	1	2	150.00	5		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7006	018	0	1	04	01	H7006_018_0	5	2				2				2				2		2	2	1	2	150.00	5		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7006	021	0	1	04	01	H7006_021_0	2	2				2				2				2		2	2	1	2	400.00	5		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7006	022	0	1	04	01	H7006_022_0	6	2				2				2				2		2	2	1	2	300.00	4		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	005	0	1	01	01	H7020_005_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		1050.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	010	1	1	01	01	H7020_010_1	7	2				2				1	35.00	35.00	35.00	2		1	2	1		700.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	010	2	1	01	01	H7020_010_2	7	2				2				1	45.00	45.00	45.00	2		1	2	1		750.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	010	3	1	01	01	H7020_010_3	7	2				2				1	40.00	40.00	40.00	2		1	2	1		500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	011	1	1	01	01	H7020_011_1	7	2				2				1	10.00	10.00	10.00	2		1	2	1		1000.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	011	2	1	01	01	H7020_011_2	7	2				2				1	10.00	10.00	10.00	2		1	2	1		1300.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	011	3	1	01	01	H7020_011_3	7	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	012	0	1	01	01	H7020_012_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		1300.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	801	0	1	01	01	H7020_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7027	001	0	1	20	08	H7027_001_0	1																																																																																																																																																																																																																																																																																																						
H7027	002	0	1	20	08	H7027_002_0	1																																																																																																																																																																																																																																																																																																						
H7028	001	0	1	04	01	H7028_001_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	002	0	1	04	01	H7028_002_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7028	003	0	1	04	01	H7028_003_0	1	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	004	0	1	04	01	H7028_004_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	005	0	1	04	01	H7028_005_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	006	0	1	04	01	H7028_006_0	5	2				1	30	30	30	2				2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	007	0	1	04	01	H7028_007_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H7028	008	0	1	04	01	H7028_008_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H7028	009	0	1	04	01	H7028_009_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7028	010	0	1	04	01	H7028_010_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7028	011	0	1	04	01	H7028_011_0	5	2				1	20	20	20	2				2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	012	0	1	04	01	H7028_012_0	5	2				1	20	20	20	2				2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	013	0	1	04	01	H7028_013_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	014	0	1	04	01	H7028_014_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	015	0	1	04	01	H7028_015_0	4	2				1	30	30	30	2				2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	016	0	1	04	01	H7028_016_0	4	2				1	30	30	30	2				2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	017	0	1	04	01	H7028_017_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H7028	018	0	1	04	01	H7028_018_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H7028	019	0	1	04	01	H7028_019_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7028	020	0	1	04	01	H7028_020_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7028	021	0	1	04	01	H7028_021_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7028	022	0	1	04	01	H7028_022_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	023	0	1	04	01	H7028_023_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	024	0	1	04	01	H7028_024_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	025	0	1	04	01	H7028_025_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7028	026	0	1	04	01	H7028_026_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	027	0	1	04	01	H7028_027_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	028	0	1	04	01	H7028_028_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	029	0	1	04	01	H7028_029_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	030	0	1	04	01	H7028_030_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	031	0	1	04	01	H7028_031_0	4	2				1	30	30	30	2				2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	032	0	1	04	01	H7028_032_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	034	0	1	04	01	H7028_034_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	035	0	1	04	01	H7028_035_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	036	0	1	04	01	H7028_036_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	037	0	1	04	01	H7028_037_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	038	0	1	04	01	H7028_038_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H7028	039	0	1	04	01	H7028_039_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H7028	040	0	1	04	01	H7028_040_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	041	0	1	04	01	H7028_041_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	042	0	1	04	01	H7028_042_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	043	0	1	04	01	H7028_043_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	044	0	1	04	01	H7028_044_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7028	045	0	1	04	01	H7028_045_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7059	001	0	1	20	08	H7059_001_0	1																																																																																																																																																																																																																																																																																																						
H7059	002	0	1	20	08	H7059_002_0	1																																																																																																																																																																																																																																																																																																						
H7063	001	0	1	04	01	H7063_001_0	5	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1200.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		4	2	1	3		1	50	50	50	2				2	2	4	2	1	3		1	50	50	50	2				2	2	4	2	1	3		1	50	50	50	2				2	2	4	2	1	3		1	50	50	50	2				2	2																															4	2	1	3		1	50	50	50	2				2	2	4	2	1	3		1	50	50	50	2				2	2																4	2	1	3		1	50	50	50	2				2	2
H7063	007	0	1	04	01	H7063_007_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2																															4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2																4	2	1	3		2				2				2	2
H7063	012	0	1	04	01	H7063_012_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																															2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H7063	013	0	1	04	01	H7063_013_0	3	2				2				1	50.00	50.00	50.00	2		2	2	1	2	2500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																															2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H7063	801	0	1	04	01	H7063_801_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7063	802	0	1	04	01	H7063_802_0	1	2				1	30	30	30	2				2		2	2																																																																																																																																																																																																																																																																																						
H7074	001	0	1	04	01	H7074_001_0	9	2				2				2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H7074	801	0	1	04	01	H7074_801_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H7074	802	0	1	04	01	H7074_802_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H7074	803	0	1	04	01	H7074_803_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H7074	804	0	1	04	01	H7074_804_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H7093	001	0	1	04	01	H7093_001_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7093	002	0	1	04	01	H7093_002_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2750.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7114	001	0	1	20	08	H7114_001_0	1																																																																																																																																																																																																																																																																																																						
H7114	002	0	1	20	08	H7114_002_0	1																																																																																																																																																																																																																																																																																																						
H7123	001	0	1	01	01	H7123_001_0	9	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every six months. A panoramic x-ray is offered at a periodicity of 1 every 60 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		3000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H7147	001	0	1	01	01	H7147_001_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7147	003	0	1	01	01	H7147_003_0	5	2				1	30	30	30	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	004	0	1	01	01	H7147_004_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7147	007	0	1	01	01	H7147_007_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	009	0	1	01	01	H7147_009_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	010	0	1	01	01	H7147_010_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	011	0	1	01	01	H7147_011_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	012	0	1	01	01	H7147_012_0	5	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	013	0	1	01	01	H7147_013_0	5	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	014	0	1	01	01	H7147_014_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		1750.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7147	015	0	1	01	01	H7147_015_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7147	016	0	1	01	01	H7147_016_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7147	017	0	1	01	01	H7147_017_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		2500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7147	018	0	1	01	01	H7147_018_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		2000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7147	019	0	1	01	01	H7147_019_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7147	020	0	1	01	01	H7147_020_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		2500.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7147	021	0	1	01	01	H7147_021_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		2000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7149	001	0	1	02	01	H7149_001_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H7149	006	0	1	01	01	H7149_006_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H7149	007	0	1	02	01	H7149_007_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H7149	801	0	1	01	01	H7149_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7151	001	0	1	01	01	H7151_001_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7151	003	0	1	01	01	H7151_003_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7151	005	0	1	01	01	H7151_005_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7151	006	0	1	01	01	H7151_006_0	4	2				1	30	30	30	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7151	007	0	1	01	01	H7151_007_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7151	008	0	1	01	01	H7151_008_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7191	001	0	1	04	01	H7191_001_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7191	002	0	1	04	01	H7191_002_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7191	003	0	1	04	01	H7191_003_0	4	2				1	30	30	30	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7191	004	0	1	04	01	H7191_004_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7191	005	0	1	04	01	H7191_005_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7191	006	0	1	04	01	H7191_006_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7195	001	0	1	20	08	H7195_001_0	1																																																																																																																																																																																																																																																																																																						
H7195	002	0	1	20	08	H7195_002_0	1																																																																																																																																																																																																																																																																																																						
H7199	002	0	1	04	01	H7199_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7220	004	0	1	02	01	H7220_004_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7220	009	1	1	02	01	H7220_009_1	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7220	009	2	1	02	01	H7220_009_2	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7220	010	0	1	02	01	H7220_010_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7233	001	0	1	20	08	H7233_001_0	1																																																																																																																																																																																																																																																																																																						
H7233	002	0	1	20	08	H7233_002_0	1																																																																																																																																																																																																																																																																																																						
H7239	001	0	1	01	01	H7239_001_0	7	2				2				2				2		2	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 0% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7239	002	0	1	01	01	H7239_002_0	6	2				2				2				2		2	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 0% coinsurance for full mouth debridement.  All other covered codes at 0% coinsurance at 1 per site/quad every 2 calendar years.	2				2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	2				2				2	2																															2	2	1	6	Once per arch per 5 years	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7239	003	0	1	01	01	H7239_003_0	7	2				2				2				2		2	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7239	004	0	1	01	01	H7239_004_0	5	2				2				2				2		2	2	1		1250.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7239	005	0	1	01	01	H7239_005_0	6	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 0% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7239	006	0	1	02	01	H7239_006_0	4	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H7262	001	0	1	20	08	H7262_001_0	1																																																																																																																																																																																																																																																																																																						
H7262	002	0	1	20	08	H7262_002_0	1																																																																																																																																																																																																																																																																																																						
H7284	008	0	1	04	01	H7284_008_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2																																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7284	009	0	1	04	01	H7284_009_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7284	010	0	1	04	01	H7284_010_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7284	011	0	1	04	01	H7284_011_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7284	012	0	1	04	01	H7284_012_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7284	013	0	1	04	01	H7284_013_0	5	2				1	20	20	20	2				2		1	2	1	2	6000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7296	001	0	1	20	08	H7296_001_0	1																																																																																																																																																																																																																																																																																																						
H7296	002	0	1	20	08	H7296_002_0	1																																																																																																																																																																																																																																																																																																						
H7301	002	0	1	04	01	H7301_002_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H7301	006	0	1	04	01	H7301_006_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H7301	007	0	1	04	01	H7301_007_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H7301	009	0	1	04	01	H7301_009_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H7301	013	0	1	04	01	H7301_013_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2250.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H7301	023	0	1	04	01	H7301_023_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H7301	033	0	1	04	01	H7301_033_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H7301	803	0	1	04	01	H7301_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7318	001	0	1	01	01	H7318_001_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H7323	801	0	1	04	01	H7323_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7326	001	0	1	04	01	H7326_001_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H7326	007	0	1	04	01	H7326_007_0	4	2				2				1	15.00	15.00	15.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H7355	001	0	1	04	01	H7355_001_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7355	002	0	1	04	01	H7355_002_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7355	003	0	1	04	01	H7355_003_0	5	2				1	30	30	30	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7355	004	0	1	04	01	H7355_004_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7355	006	0	1	04	01	H7355_006_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7355	007	0	1	04	01	H7355_007_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7355	009	0	1	04	01	H7355_009_0	5	2				1	30	30	30	2				2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7355	010	0	1	04	01	H7355_010_0	5	2				1	30	30	30	2				2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7355	011	0	1	04	01	H7355_011_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7355	012	0	1	04	01	H7355_012_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7366	001	0	1	20	08	H7366_001_0	1																																																																																																																																																																																																																																																																																																						
H7366	002	0	1	20	08	H7366_002_0	1																																																																																																																																																																																																																																																																																																						
H7379	001	0	1	04	01	H7379_001_0	10	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					1	110110	0.00	0.00	0.00	2		2	2	1	6	Frequencies vary based on type of services.	2								2	2	2	2	1	6	Frequencies vary based on type of services.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	2	2	1200.00	3		2		2					2		2	2	1	6	Frequencies vary based on type of services.	2				3		15.00	400.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		100.00	200.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		50.00	300.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		30.00	700.00	1	2																2	2	1	6	Frequencies vary based on service.	2				3		70.00	500.00	1	2	2	2	1	6	Frequency varies by service.	2				3		40.00	400.00	1	2	2	2	1	6	one tooth per lifetime	2				3		40.00	100.00	1	2																2	2	1	6	Frequencies vary by service	2				3		15.00	30.00	1	2
H7379	002	0	1	04	01	H7379_002_0	10	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1700.00	3		2		2					2		2	2	1	6	Frequencies vary based on type of services.	2				3		15.00	400.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		100.00	200.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		50.00	300.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		30.00	700.00	1	2																2	2	1	6	Frequencies vary based on service.	2				3		70.00	500.00	1	2	2	2	1	6	Frequency varies by service.	2				3		40.00	400.00	1	2	2	2	1	6	one tooth per lifetime	2				3		40.00	100.00	1	2																2	2	1	6	Frequencies vary by service	2				3		15.00	30.00	1	2
H7379	003	0	1	04	01	H7379_003_0	10	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1000.00	3		2		2					2		2	2	1	6	Frequencies vary based on type of services.	2				3		15.00	400.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		100.00	200.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		50.00	300.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		30.00	700.00	1	2																2	2	1	6	Frequencies vary based on service.	2				3		70.00	500.00	1	2	2	2	1	6	Frequency varies by service.	2				3		40.00	400.00	1	2	2	2	1	6	one tooth per lifetime	2				3		40.00	100.00	1	2																2	2	1	6	Frequency varies by service	2				3		15.00	30.00	1	2
H7379	004	1	1	04	01	H7379_004_1	11	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	2	2	500.00	3				2					2		2	2	1	6	Frequencies vary based on type of services.	2				3		15.00	400.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		100.00	200.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		50.00	300.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		30.00	700.00	1	2																2	2	1	6	Frequencies vary based on service.	2				3		70.00	500.00	1	2	2	2	1	6	Frequency varies by service.	2				3		40.00	400.00	1	2	2	2	1	6	one tooth per lifetime	2				3		40.00	100.00	1	2																2	2	1	6	Frequencies vary by service	2				3		15.00	30.00	1	2
H7379	004	2	1	04	01	H7379_004_2	11	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	2	2	500.00	3				2					2		2	2	1	6	Frequencies vary based on type of services.	2				3		15.00	400.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		100.00	200.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		50.00	300.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		30.00	700.00	1	2																2	2	1	6	Frequencies vary based on service.	2				3		70.00	500.00	1	2	2	2	1	6	Frequency varies by service.	2				3		40.00	400.00	1	2	2	2	1	6	one tooth per lifetime	2				3		40.00	100.00	1	2																2	2	1	6	Frequencies vary by service	2				3		15.00	30.00	1	2
H7379	801	0	1	04	01	H7379_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7379	802	0	1	04	01	H7379_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7379	803	0	1	04	01	H7379_803_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7379	804	0	1	04	01	H7379_804_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7389	801	0	1	01	01	H7389_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7397	001	0	1	04	01	H7397_001_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7397	002	0	1	04	01	H7397_002_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7397	003	0	1	04	01	H7397_003_0	5	2				1	30	30	30	2				2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7397	004	0	1	04	01	H7397_004_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7397	006	0	1	04	01	H7397_006_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7397	007	0	1	04	01	H7397_007_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7397	009	0	1	04	01	H7397_009_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7397	010	0	1	04	01	H7397_010_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7397	011	0	1	04	01	H7397_011_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7397	012	0	1	04	01	H7397_012_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7435	001	0	1	01	01	H7435_001_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H7435	002	0	1	01	01	H7435_002_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2		2					2		2	2	1	6	Every 1 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H7440	001	0	1	02	01	H7440_001_0	10	2				2				3		0.00	25.00	2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H7464	008	1	1	01	01	H7464_008_1	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7464	008	2	1	01	01	H7464_008_2	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7464	010	0	1	01	01	H7464_010_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7464	012	0	1	01	01	H7464_012_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7469	001	0	1	20	08	H7469_001_0	1																																																																																																																																																																																																																																																																																																						
H7469	002	0	1	20	08	H7469_002_0	1																																																																																																																																																																																																																																																																																																						
H7471	001	0	1	04	01	H7471_001_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	002	0	1	04	01	H7471_002_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7471	004	0	1	04	01	H7471_004_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	005	0	1	04	01	H7471_005_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	006	0	1	04	01	H7471_006_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7471	007	0	1	04	01	H7471_007_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	008	0	1	04	01	H7471_008_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	009	0	1	04	01	H7471_009_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7471	011	0	1	04	01	H7471_011_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	012	0	1	04	01	H7471_012_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7471	013	0	1	04	01	H7471_013_0	5	2				1	30	30	30	2				2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7471	014	0	1	04	01	H7471_014_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7471	015	0	1	04	01	H7471_015_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7471	016	0	1	04	01	H7471_016_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7471	017	0	1	04	01	H7471_017_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7471	019	0	1	04	01	H7471_019_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	020	0	1	04	01	H7471_020_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	021	0	1	04	01	H7471_021_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	022	0	1	04	01	H7471_022_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	023	0	1	04	01	H7471_023_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	024	0	1	04	01	H7471_024_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	025	0	1	04	01	H7471_025_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7471	026	0	1	04	01	H7471_026_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7501	001	0	1	20	08	H7501_001_0	2																																																																																																																																																																																																																																																																																																						
H7501	002	0	1	20	08	H7501_002_0	2																																																																																																																																																																																																																																																																																																						
H7511	003	0	1	01	01	H7511_003_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7511	004	0	1	01	01	H7511_004_0	10	2				2				1	30.00	30.00	30.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	2		2000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	2	1	6	Implants are covered once per tooth per five-year period.	2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every 2 years. Bridges are covered with a $500 limit once in a five year period.	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7512	801	0	1	04	01	H7512_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7518	001	0	1	04	01	H7518_001_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H7518	002	0	1	04	01	H7518_002_0	3	2				2				1	10.00	10.00	10.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H7518	003	0	1	04	01	H7518_003_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H7522	801	0	1	04	01	H7522_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	802	0	1	04	01	H7522_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	804	0	1	04	01	H7522_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	805	0	1	04	01	H7522_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	806	0	1	04	01	H7522_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	807	0	1	04	01	H7522_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	808	0	1	04	01	H7522_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	809	0	1	04	01	H7522_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	810	0	1	04	01	H7522_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	811	0	1	04	01	H7522_811_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	812	0	1	04	01	H7522_812_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	813	0	1	04	01	H7522_813_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	814	0	1	04	01	H7522_814_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	815	0	1	04	01	H7522_815_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	816	0	1	04	01	H7522_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7522	817	0	1	04	01	H7522_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H7524	001	0	1	01	01	H7524_001_0	6	2				1	30	30	30	2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	1				2				2				1	2	2								2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H7524	002	0	1	01	01	H7524_002_0	6	2				1	30	30	30	2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	1				2				2				1	2	2								2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H7524	003	0	1	01	01	H7524_003_0	6	2				1	30	30	30	2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	1				2				2				1	2	2								2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H7524	004	0	1	01	01	H7524_004_0	7	2				1	30	30	30	2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	1				2				2				1	2	2								2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H7557	001	0	1	01	01	H7557_001_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7598	003	0	1	01	01	H7598_003_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7598	004	0	1	01	01	H7598_004_0	8	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H7605	001	0	1	01	01	H7605_001_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7605	002	0	1	01	01	H7605_002_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7605	004	0	1	01	01	H7605_004_0	7	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7605	005	0	1	01	01	H7605_005_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7605	007	0	1	01	01	H7605_007_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7605	008	0	1	01	01	H7605_008_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7605	009	0	1	01	01	H7605_009_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7605	010	0	1	01	01	H7605_010_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7605	016	0	1	01	01	H7605_016_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7607	014	0	1	01	01	H7607_014_0	7	2				2				2				2		1	2	1		1250.00	4		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	0	6	Not covered.	2				2				2	2	1	1							2					2		2	2	1	2		2				2				1	2	2	2	1	6	1 per tooth per lifetime	2				2				1	2	2	2	1	2		2				2				1	2	2	2	1	6	No Limit	2				2				1	2																2	2	1	6	Abutment support crown - 1 per tooth every 5 calendar years	2				2				1	2	2	2	1	6	1 per tooth, every 5 calendar years	2				2				1	2	2	2	1	6	Oral and Maxillofacial Surgery services have limitations based on the type of service.	2				2				1	2																2	2	1	6	Occlusal guard - 1 every 3 calendar years	2				2				2	2
H7607	015	0	1	01	01	H7607_015_0	7	2				2				2				2		1	2	1		500.00	4		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	0	6	Not covered.	2				2				2	2	1	1							2					2		2	2	1	2		2				2				1	2	2	2	1	6	Per tooth per lifetime	2				2				1	2	2	2	1	2		2				2				1	2	2	2	1	6	No Limit	2				2				1	2																2	2	1	6	Abutment support crown - 1 per tooth every 5 calendar years	2				2				1	2	2	2	1	6	1 per tooth, every 5 calendar years	2				2				1	2	2	2	1	6	Oral and Maxillofacial Surgery services have limitations based on the type of service.	2				2				1	2																2	2	1	6	Occlusal guard - 1 every 3 calendar years	2				2				2	2
H7607	016	0	1	01	01	H7607_016_0	7	2				2				2				2		1	2	1		1300.00	4		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	0	6	Not covered.	2				2				2	2	1	1							2					2		2	2	1	2		2				2				1	2	2	2	1	6	per tooth per lifetime	2				2				1	2	2	2	1	2		2				2				1	2	2	2	1	6	No limit	2				2				1	2																2	2	1	6	Abutment support crown - 1 per tooth every 5 calendar years	2				2				1	2	2	2	1	6	1 per tooth, every 5 calendar years	2				2				1	2	2	2	1	6	Oral and Maxillofacial Surgery services have limitations based on the type of service.	2				2				1	2																2	2	1	6	Occlusal guard - 1 every 3 calendar years	2				2				2	2
H7607	017	0	1	01	01	H7607_017_0	7	2				2				2				2		1	2	1		1300.00	4		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	0	6	Not covered.	2				2				2	2	1	1							2					2		2	2	1	2		2				2				1	2	2	2	1	6	per tooth, per lifetime	2				2				1	2	2	2	1	2		2				2				1	2	2	2	1	6	No limit	2				2				1	2																2	2	1	6	Abutment support crown - 1 per tooth every 5 calendar years	2				2				1	2	2	2	1	6	1 per tooth, every 5 calendar years	2				2				1	2	2	2	1	6	Oral and Maxillofacial Surgery services have limitations based on the type of service.	2				2				1	2																2	2	1	6	Occlusal guard - 1 every 3 calendar years	2				2				2	2
H7607	018	0	1	01	01	H7607_018_0	7	2				2				2				2		1	2	1		1250.00	4		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	0	6	Not covered.	2				2				2	2	1	1							2					2		2	2	1	2		2				2				1	2	2	2	1	6	per tooth, per lifetime	2				2				1	2	2	2	1	2		2				2				1	2	2	2	1	6	No Limit	2				2				1	2																2	2	1	6	Abutment support crown - 1 per tooth every 5 calendar years	2				2				1	2	2	2	1	6	1 per tooth, every 5 calendar years	2				2				1	2	2	2	1	6	Oral and Maxillofacial Surgery services have limitations based on the type of service.	2				2				1	2																2	2	1	6	Occlusal guard - 1 every 3 calendar years	2				2				2	2
H7607	019	0	1	01	01	H7607_019_0	7	2				2				2				2		1	2	1		1250.00	4		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	0	6	Not covered.	2				2				2	2	1	1							2					2		2	2	1	2		2				2				2	2	2	2	1	6	per tooth, per lifetime	2				2				2	2	2	2	1	2		2				2				2	2	2	2	1	6	No Limit	2				2				2	2																2	2	1	6	Abutment support crown - 1 per tooth every 5 calendar years	2				2				2	2	2	2	1	6	1 per tooth, every 5 calendar years	2				2				2	2	2	2	1	6	Oral and Maxillofacial Surgery services have limitations based on the type of service.	2				2				2	2																2	2	1	6	Occlusal guard - 1 every 3 calendar years	2				2				2	2
H7617	004	0	1	04	01	H7617_004_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	006	0	1	04	01	H7617_006_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	007	0	1	04	01	H7617_007_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	008	0	1	04	01	H7617_008_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	010	0	1	04	01	H7617_010_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	011	0	1	04	01	H7617_011_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	012	0	1	04	01	H7617_012_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	013	0	1	04	01	H7617_013_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	014	0	1	04	01	H7617_014_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	015	0	1	04	01	H7617_015_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	016	0	1	04	01	H7617_016_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	017	0	1	04	01	H7617_017_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	018	0	1	04	01	H7617_018_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	020	0	1	04	01	H7617_020_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	021	0	1	04	01	H7617_021_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	022	0	1	04	01	H7617_022_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	023	0	1	04	01	H7617_023_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	024	0	1	04	01	H7617_024_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	3	2		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				3		0.00	25.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	025	0	1	04	01	H7617_025_0	6	2				2				1	10.00	10.00	10.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	026	0	1	04	01	H7617_026_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	027	0	1	04	01	H7617_027_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	3	2		2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	028	0	1	04	01	H7617_028_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	029	0	1	04	01	H7617_029_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	030	0	1	04	01	H7617_030_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	031	0	1	04	01	H7617_031_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	032	0	1	04	01	H7617_032_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	033	0	1	04	01	H7617_033_0	5	2				1	20	20	20	2				2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	035	0	1	04	01	H7617_035_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	036	0	1	04	01	H7617_036_0	4	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	037	0	1	04	01	H7617_037_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	038	0	1	04	01	H7617_038_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	039	0	1	04	01	H7617_039_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	041	0	1	04	01	H7617_041_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	5000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	042	0	1	04	01	H7617_042_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	043	0	1	04	01	H7617_043_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	044	0	1	04	01	H7617_044_0	4	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	045	0	1	04	01	H7617_045_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	046	0	1	04	01	H7617_046_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	048	0	1	04	01	H7617_048_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	049	0	1	04	01	H7617_049_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	050	0	1	04	01	H7617_050_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	051	0	1	04	01	H7617_051_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	052	0	1	04	01	H7617_052_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	053	0	1	04	01	H7617_053_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	054	0	1	04	01	H7617_054_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	056	0	1	04	01	H7617_056_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	057	0	1	04	01	H7617_057_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	058	0	1	04	01	H7617_058_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	3	2		2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	059	0	1	04	01	H7617_059_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	061	0	1	04	01	H7617_061_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	062	0	1	04	01	H7617_062_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	063	0	1	04	01	H7617_063_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	064	0	1	04	01	H7617_064_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	065	0	1	04	01	H7617_065_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	3	2		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				3		0.00	25.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	066	0	1	04	01	H7617_066_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	067	0	1	04	01	H7617_067_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	068	0	1	04	01	H7617_068_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	069	0	1	04	01	H7617_069_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	070	0	1	04	01	H7617_070_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	073	0	1	04	01	H7617_073_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	074	0	1	04	01	H7617_074_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	075	0	1	04	01	H7617_075_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	076	0	1	04	01	H7617_076_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	077	0	1	04	01	H7617_077_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	078	0	1	04	01	H7617_078_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	079	0	1	04	01	H7617_079_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	080	0	1	04	01	H7617_080_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	081	0	1	04	01	H7617_081_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	082	0	1	04	01	H7617_082_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	083	0	1	04	01	H7617_083_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	084	0	1	04	01	H7617_084_0	4	2				1	20	20	20	2				2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	085	0	1	04	01	H7617_085_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	086	0	1	04	01	H7617_086_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	087	0	1	04	01	H7617_087_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	088	0	1	04	01	H7617_088_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	089	0	1	04	01	H7617_089_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	090	0	1	04	01	H7617_090_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	091	0	1	04	01	H7617_091_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	092	0	1	04	01	H7617_092_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	093	0	1	04	01	H7617_093_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	094	0	1	04	01	H7617_094_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	095	0	1	04	01	H7617_095_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	096	0	1	04	01	H7617_096_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	098	0	1	04	01	H7617_098_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	100	0	1	04	01	H7617_100_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	101	0	1	04	01	H7617_101_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	107	0	1	04	01	H7617_107_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	108	0	1	04	01	H7617_108_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	110	0	1	04	01	H7617_110_0	6	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2																																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	114	0	1	04	01	H7617_114_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	115	0	1	04	01	H7617_115_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	116	0	1	04	01	H7617_116_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	117	0	1	04	01	H7617_117_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	118	0	1	04	01	H7617_118_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	119	0	1	04	01	H7617_119_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	120	0	1	04	01	H7617_120_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	121	0	1	04	01	H7617_121_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
H7617	122	0	1	04	01	H7617_122_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	123	0	1	04	01	H7617_123_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	124	0	1	04	01	H7617_124_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	125	0	1	04	01	H7617_125_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	126	0	1	04	01	H7617_126_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	127	0	1	04	01	H7617_127_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
H7617	128	0	1	04	01	H7617_128_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	129	0	1	04	01	H7617_129_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	130	0	1	04	01	H7617_130_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	131	0	1	04	01	H7617_131_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	132	0	1	04	01	H7617_132_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	133	0	1	04	01	H7617_133_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	134	0	1	04	01	H7617_134_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	135	0	1	04	01	H7617_135_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	136	0	1	04	01	H7617_136_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	137	0	1	04	01	H7617_137_0	4	2				1	20	20	20	2				2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	138	0	1	04	01	H7617_138_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	139	0	1	04	01	H7617_139_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	140	0	1	04	01	H7617_140_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	142	0	1	04	01	H7617_142_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	143	0	1	04	01	H7617_143_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	144	1	1	04	01	H7617_144_1	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3				2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	144	2	1	04	01	H7617_144_2	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3				2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	145	0	1	04	01	H7617_145_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H7617	801	0	1	04	01	H7617_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7617	802	0	1	04	01	H7617_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7617	803	0	2	04	01	H7617_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7617	804	0	2	04	01	H7617_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7617	805	0	1	04	01	H7617_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7617	806	0	1	04	01	H7617_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7617	807	0	1	04	01	H7617_807_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7617	808	0	1	04	01	H7617_808_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7617	811	0	1	04	01	H7617_811_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7617	812	0	1	04	01	H7617_812_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7617	817	0	1	04	01	H7617_817_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7617	818	0	1	04	01	H7617_818_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7619	001	0	1	20	08	H7619_001_0	1																																																																																																																																																																																																																																																																																																						
H7619	002	0	1	20	08	H7619_002_0	1																																																																																																																																																																																																																																																																																																						
H7620	001	0	1	01	01	H7620_001_0	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7635	001	0	1	01	01	H7635_001_0	5	2				1	20	20	20	2				2		1	2	1		1250.00	3		2		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	6	Benefit covers 1 Bitewing X-Ray, 1 Full-Mouth X-Ray every 5 years, and Single X-Rays as needed.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	2	1	6	One procedure per tooth per lifetime.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Once every 60 months.	2				2				2	2																															2	2	1	6	Once every 60 months.	2				2				2	2	2	1				2				2				2	2																														
H7656	001	0	1	20	08	H7656_001_0	4																																																																																																																																																																																																																																																																																																						
H7656	002	0	1	20	08	H7656_002_0	5																																																																																																																																																																																																																																																																																																						
H7660	001	0	1	20	08	H7660_001_0	1																																																																																																																																																																																																																																																																																																						
H7660	002	0	1	20	08	H7660_002_0	1																																																																																																																																																																																																																																																																																																						
H7678	006	1	1	01	01	H7678_006_1	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H7678	006	2	1	01	01	H7678_006_2	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H7680	001	0	1	01	01	H7680_001_0	7	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7680	002	0	1	01	01	H7680_002_0	7	2				2				2				2		2	2	1		2600.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7680	007	0	1	01	01	H7680_007_0	7	2				2				2				2		2	2	1		3400.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 0% coinsurance for full mouth debridement.  All other covered codes at 0% coinsurance at 1 per site/quad every 2 calendar years.	2				2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	2				2				2	2																															2	2	1	6	Once per arch per 5 years	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7680	009	0	1	01	01	H7680_009_0	7	2				2				2				2		2	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7680	012	0	1	01	01	H7680_012_0	6	2				2				2				2		2	2	1		750.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7680	014	0	1	01	01	H7680_014_0	7	2				2				2				2		2	2	1		750.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7680	015	0	1	01	01	H7680_015_0	7	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7680	016	0	1	01	01	H7680_016_0	7	2				2				2				2		2	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7680	017	0	1	01	01	H7680_017_0	6	2				2				2				2		2	2	1		3400.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 0% coinsurance for full mouth debridement.  All other covered codes at 0% coinsurance at 1 per site/quad every 2 calendar years.	2				2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	2				2				2	2																															2	2	1	6	Once per arch per 5 years	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7680	018	0	1	01	01	H7680_018_0	7	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7680	019	0	1	02	01	H7680_019_0	7	2				2				2				2		2	2	1		3050.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7680	020	0	1	01	01	H7680_020_0	5	2				2				2				2		2	2	1		750.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																					
H7680	021	0	1	01	01	H7680_021_0	7	2				2				2				2		2	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	2	1	6	Periodontal Maintenance at 0% coinsurance (2 of prophylaxis, scaling, or periodontal maintenance). 10% coinsurance for full mouth debridement.  All other covered codes at 50% coinsurance at 1 per site/quad every 2 calendar years.	3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7680	801	0	1	01	01	H7680_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7710	001	0	1	01	01	H7710_001_0	12	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	1							2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 2 per year, 1 crown in 5 years per tooth.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																																														2	1				2				2				2	2																														
H7710	002	0	1	01	01	H7710_002_0	12	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	4		2				1	10.00	10.00	10.00	2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	2		1500.00	3		2		2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 1 per year, 1 crown in 5 years per tooth.	1	25	25	25	2				2	2	2	2	1	3		1	25	25	25	2				2	2	2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Dentures are covered one per arch every 5 years, including a full denture, a partial denture or an immediate denture and are not applied to the comprehensive maximum plan coverage amount.	1	25	25	25	2				2	2																																														2	1				1	25	25	25	2				2	2																														
H7725	001	0	1	20	08	H7725_001_0	1																																																																																																																																																																																																																																																																																																						
H7725	002	0	1	20	08	H7725_002_0	1																																																																																																																																																																																																																																																																																																						
H7766	001	0	1	04	01	H7766_001_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7766	002	0	1	04	01	H7766_002_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7766	004	0	1	04	01	H7766_004_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	005	0	1	04	01	H7766_005_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7766	006	0	1	04	01	H7766_006_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7766	012	0	1	04	01	H7766_012_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	013	0	1	04	01	H7766_013_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	014	0	1	04	01	H7766_014_0	4	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	015	0	1	04	01	H7766_015_0	4	2				1	30	30	30	2				2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	016	0	1	04	01	H7766_016_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7766	017	0	1	04	01	H7766_017_0	3	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7766	018	0	1	04	01	H7766_018_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	019	0	1	04	01	H7766_019_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7766	020	0	1	04	01	H7766_020_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7766	021	0	1	04	01	H7766_021_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2200.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7766	022	0	1	04	01	H7766_022_0	4	2				1	30	30	30	2				2		1	2	1	2	2700.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	023	0	1	04	01	H7766_023_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	024	0	1	04	01	H7766_024_0	3	2				1	30	30	30	2				2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	025	0	1	04	01	H7766_025_0	5	2				1	30	30	30	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	026	0	1	04	01	H7766_026_0	5	2				1	30	30	30	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	027	0	1	04	01	H7766_027_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7766	028	0	1	04	01	H7766_028_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7766	029	0	1	04	01	H7766_029_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2200.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7777	001	0	1	20	08	H7777_001_0	1																																																																																																																																																																																																																																																																																																						
H7777	002	0	1	20	08	H7777_002_0	1																																																																																																																																																																																																																																																																																																						
H7779	001	0	1	01	01	H7779_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7787	801	0	1	04	01	H7787_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	802	0	1	04	01	H7787_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	803	0	1	04	01	H7787_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	804	0	1	04	01	H7787_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	805	0	1	04	01	H7787_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	806	0	1	04	01	H7787_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	807	0	1	04	01	H7787_807_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	808	0	1	04	01	H7787_808_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	809	0	1	04	01	H7787_809_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	810	0	1	04	01	H7787_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	811	0	1	04	01	H7787_811_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	812	0	1	04	01	H7787_812_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	813	0	1	04	01	H7787_813_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	814	0	1	04	01	H7787_814_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	815	0	1	04	01	H7787_815_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	816	0	1	04	01	H7787_816_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	817	0	1	04	01	H7787_817_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	818	0	1	04	01	H7787_818_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	819	0	1	04	01	H7787_819_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	820	0	1	04	01	H7787_820_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	821	0	1	04	01	H7787_821_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	822	0	1	04	01	H7787_822_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	823	0	1	04	01	H7787_823_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	824	0	1	04	01	H7787_824_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	825	0	1	04	01	H7787_825_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	826	0	1	04	01	H7787_826_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7787	827	0	1	04	01	H7787_827_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7831	001	0	1	20	08	H7831_001_0	1																																																																																																																																																																																																																																																																																																						
H7831	002	0	1	20	08	H7831_002_0	1																																																																																																																																																																																																																																																																																																						
H7849	002	0	1	04	01	H7849_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	600.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	015	0	1	04	01	H7849_015_0	9	2				2				1	45.00	45.00	45.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	065	0	1	04	01	H7849_065_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1200.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	070	0	1	04	01	H7849_070_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	850.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	080	0	1	04	01	H7849_080_0	8	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	088	0	1	04	01	H7849_088_0	8	2				2				1	50.00	50.00	50.00	2		1	2	1	2	900.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	102	1	1	04	01	H7849_102_1	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	102	2	1	04	01	H7849_102_2	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	102	3	1	04	01	H7849_102_3	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	600.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	106	0	1	04	01	H7849_106_0	9	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2200.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	113	1	1	04	01	H7849_113_1	7	2				2				1	45.00	45.00	45.00	2		1	2	1	2	800.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	113	3	1	04	01	H7849_113_3	11	2				2				1	30.00	30.00	30.00	2		1	2	1	2	950.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	113	4	1	04	01	H7849_113_4	7	2				2				1	45.00	45.00	45.00	2		1	2	1	2	500.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	135	0	1	04	01	H7849_135_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2400.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	136	1	1	04	01	H7849_136_1	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	600.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	136	2	1	04	01	H7849_136_2	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1200.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	136	3	1	04	01	H7849_136_3	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1200.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	143	0	1	04	01	H7849_143_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	300.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	144	0	1	04	01	H7849_144_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	300.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	145	0	1	04	01	H7849_145_0	7	2				2				1	40.00	40.00	40.00	2		1	2	1	2	400.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	146	0	1	04	01	H7849_146_0	8	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	147	0	1	04	01	H7849_147_0	7	2				2				1	40.00	40.00	40.00	2		1	2																																																																																																																																																																																																																																																																																						
H7849	149	0	1	04	01	H7849_149_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	300.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	151	0	1	04	01	H7849_151_0	8	2				2				1	45.00	45.00	45.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	153	0	1	04	01	H7849_153_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	154	0	1	04	01	H7849_154_0	8	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	155	0	1	04	01	H7849_155_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	550.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	156	0	1	04	01	H7849_156_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	835	0	1	04	01	H7849_835_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7849	836	0	1	04	01	H7849_836_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H7855	001	0	1	20	08	H7855_001_0	1																																																																																																																																																																																																																																																																																																						
H7855	002	0	1	20	08	H7855_002_0	1																																																																																																																																																																																																																																																																																																						
H7917	009	0	1	04	01	H7917_009_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	20	20	20	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	010	0	1	04	01	H7917_010_0	7	2				2				1	25.00	25.00	25.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	20	20	20	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	011	0	1	04	01	H7917_011_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	20	20	20	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	012	0	1	04	01	H7917_012_0	6	2				2				1	39.00	39.00	39.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	20	20	20	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	013	0	1	04	01	H7917_013_0	6	2				2				1	39.00	39.00	39.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	20	20	20	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	014	0	1	04	01	H7917_014_0	7	2				2				1	39.00	39.00	39.00	2		1	2	1	2	2750.00	3		2		2				2					2					2		2	2	2	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	20	20	20	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	015	0	1	04	01	H7917_015_0	6	2				2				1	39.00	39.00	39.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	20	20	20	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	030	0	1	04	01	H7917_030_0	6	2				2				1	39.00	39.00	39.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	20	20	20	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	031	0	1	04	01	H7917_031_0	7	2				2				1	39.00	39.00	39.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	50	50	50	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	032	0	1	04	01	H7917_032_0	5	2				2				1	39.00	39.00	39.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	50	50	50	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	033	0	1	04	01	H7917_033_0	6	2				2				1	39.00	39.00	39.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	50	50	50	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	038	0	1	04	01	H7917_038_0	5	2				2				1	39.00	39.00	39.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	50	50	50	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	039	0	1	04	01	H7917_039_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	20	20	20	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	041	0	1	04	01	H7917_041_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	20	20	20	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	044	0	1	04	01	H7917_044_0	7	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	50	50	50	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	045	0	1	04	01	H7917_045_0	6	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	50	50	50	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	046	0	1	04	01	H7917_046_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	50	50	50	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	047	0	1	04	01	H7917_047_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	50	50	50	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	048	0	1	04	01	H7917_048_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	50	50	50	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	049	0	1	04	01	H7917_049_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 per floating 36 months.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 12 months.	1	20	20	20	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 5 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating year.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 1 per floating 6 months.	1	50	50	50	2				2	2																															2	2	1	6	Recement or re-bond fixed partial denture: 1 per floating 24 months. Fixed partial denture repair: 1 per floating 5 years. All other services: 1 every floating 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per floating day.	1	20	20	20	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per floating 5 years to unlimited.	1	20	20	20	2				2	2
H7917	801	0	1	04	01	H7917_801_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7917	802	0	1	04	01	H7917_802_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7917	803	0	1	04	01	H7917_803_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H7993	001	0	1	01	01	H7993_001_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	002	0	1	01	01	H7993_002_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	003	0	1	01	01	H7993_003_0	7	2				2				1	20.00	20.00	20.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	004	0	1	01	01	H7993_004_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	006	0	1	01	01	H7993_006_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7993	007	0	1	01	01	H7993_007_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	008	0	1	01	01	H7993_008_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	010	0	1	01	01	H7993_010_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	012	0	1	01	01	H7993_012_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	014	0	1	01	01	H7993_014_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	015	0	1	01	01	H7993_015_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	017	0	1	01	01	H7993_017_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	019	0	1	01	01	H7993_019_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	020	0	1	01	01	H7993_020_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	021	0	1	01	01	H7993_021_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7993	023	0	1	01	01	H7993_023_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	024	0	1	01	01	H7993_024_0	4	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	027	0	1	01	01	H7993_027_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	028	0	1	01	01	H7993_028_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	029	0	1	01	01	H7993_029_0	4	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	030	0	1	01	01	H7993_030_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	031	0	1	01	01	H7993_031_0	4	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	033	0	1	01	01	H7993_033_0	4	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	034	0	1	01	01	H7993_034_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	035	0	1	01	01	H7993_035_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7993	036	0	1	01	01	H7993_036_0	5	2				1	30	30	30	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	037	0	1	01	01	H7993_037_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	038	0	1	01	01	H7993_038_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	040	0	1	01	01	H7993_040_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	041	0	1	01	01	H7993_041_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	046	0	1	01	01	H7993_046_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	048	0	1	01	01	H7993_048_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7993	063	0	1	01	01	H7993_063_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	067	0	1	01	01	H7993_067_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	068	0	1	01	01	H7993_068_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7993	069	0	1	01	01	H7993_069_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	070	0	1	01	01	H7993_070_0	4	2				1	30	30	30	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	071	0	1	01	01	H7993_071_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	072	0	1	01	01	H7993_072_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	073	0	1	01	01	H7993_073_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	074	0	1	01	01	H7993_074_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7993	075	0	1	01	01	H7993_075_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	082	0	1	01	01	H7993_082_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	083	0	1	01	01	H7993_083_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	085	0	1	01	01	H7993_085_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	086	0	1	01	01	H7993_086_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	087	0	1	01	01	H7993_087_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	089	0	1	01	01	H7993_089_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	090	0	1	01	01	H7993_090_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	091	0	1	01	01	H7993_091_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7993	092	0	1	01	01	H7993_092_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	093	0	1	01	01	H7993_093_0	4	2				1	30	30	30	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	094	0	1	01	01	H7993_094_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	095	0	1	01	01	H7993_095_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7993	096	0	1	01	01	H7993_096_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	097	0	1	01	01	H7993_097_0	4	2				1	30	30	30	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	098	0	1	01	01	H7993_098_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	099	0	1	01	01	H7993_099_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H7993	100	0	1	01	01	H7993_100_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	101	0	1	01	01	H7993_101_0	4	2				1	30	30	30	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	102	0	1	01	01	H7993_102_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	103	0	1	01	01	H7993_103_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	104	0	1	01	01	H7993_104_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	105	0	1	01	01	H7993_105_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	106	0	1	01	01	H7993_106_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	107	0	1	01	01	H7993_107_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	108	0	1	01	01	H7993_108_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	109	0	1	01	01	H7993_109_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	110	0	1	01	01	H7993_110_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	112	0	1	01	01	H7993_112_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	113	0	1	01	01	H7993_113_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	114	0	1	01	01	H7993_114_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	116	0	1	01	01	H7993_116_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		4250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H7993	117	0	1	01	01	H7993_117_0	4	2				1	30	30	30	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	118	0	1	01	01	H7993_118_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	119	0	1	01	01	H7993_119_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8003	001	0	1	04	01	H8003_001_0	7	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	1	2	2	2500.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8003	002	0	1	04	01	H8003_002_0	6	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	1	2	2	2500.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8003	003	0	1	04	01	H8003_003_0	6	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	1	2	2	2500.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8003	004	0	1	04	01	H8003_004_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																					
H8003	005	0	1	04	01	H8003_005_0	5	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																					
H8003	006	0	1	04	01	H8003_006_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																					
H8003	007	0	1	04	01	H8003_007_0	6	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	1	2	2	3000.00	3		2		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8003	801	0	1	04	01	H8003_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8003	802	0	1	04	01	H8003_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8003	803	0	1	04	01	H8003_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8003	804	0	1	04	01	H8003_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8010	002	0	1	01	01	H8010_002_0	10	2				2				1	10.00	10.00	10.00	2		2	2	1		1250.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2																2	2	1	3		2				1	30.00	30.00	30.00	2	2
H8010	003	0	1	01	01	H8010_003_0	10	2				2				2				2		2	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1							2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H8048	001	0	1	20	08	H8048_001_0	2																																																																																																																																																																																																																																																																																																						
H8048	002	0	1	20	08	H8048_002_0	2																																																																																																																																																																																																																																																																																																						
H8051	001	0	1	01	01	H8051_001_0	8	2				1	20	20	20	2				2		1	2	2							2														2		2	2	1	3		2				2				2	2																																																																												2								2					2		2	2	1	6	Restorative Crowns with high noble metal - one per tooth every seven calendar years	2				2				1	2																															2	2	1	6	Prosthodontics - Rebases for full or partial dentures covered once every 2 calendar years. Replacement of all teeth & acrylic on cast metal frame covered once every 3 calendar years.	2				2				1	2																															2	2	1	6	Fixed partial dentures (bridges) with high noble metal - one per tooth every seven calendar years	2				2				1	2																															2	2	1	3		2				2				1	2
H8082	001	0	1	20	08	H8082_001_0	1																																																																																																																																																																																																																																																																																																						
H8082	002	0	1	20	08	H8082_002_0	1																																																																																																																																																																																																																																																																																																						
H8093	001	0	1	01	01	H8093_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8093	002	0	1	01	01	H8093_002_0	8	2				1	20	20	20	2				2		2	2	1		1800.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				2				2	2																														
H8096	001	0	1	20	08	H8096_001_0	1																																																																																																																																																																																																																																																																																																						
H8096	002	0	1	20	08	H8096_002_0	1																																																																																																																																																																																																																																																																																																						
H8099	001	0	1	20	08	H8099_001_0	1																																																																																																																																																																																																																																																																																																						
H8099	002	0	1	20	08	H8099_002_0	1																																																																																																																																																																																																																																																																																																						
H8121	801	0	1	04	01	H8121_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H8133	806	0	1	01	01	H8133_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8142	001	0	1	02	01	H8142_001_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months. Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2																																																																																																																																																																					
H8142	002	0	1	02	01	H8142_002_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months. Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2																																																																																																																																																																					
H8142	003	0	1	02	01	H8142_003_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months. Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2																																																																																																																																																																					
H8142	004	0	1	02	01	H8142_004_0	9	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months. Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2																																																																																																																																																																					
H8142	005	0	1	02	01	H8142_005_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months. Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2																																																																																																																																																																					
H8142	006	0	1	02	01	H8142_006_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months. Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2																																																																																																																																																																					
H8142	007	0	1	02	01	H8142_007_0	12	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months. Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2																																																																																																																																																																					
H8142	008	0	1	02	01	H8142_008_0	10	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months. Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2																																																																																																																																																																					
H8142	801	0	1	02	01	H8142_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8142	802	0	1	02	01	H8142_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8142	803	0	1	02	01	H8142_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8142	804	0	1	02	01	H8142_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8145	004	0	1	09	04	H8145_004_0	6	2				2				1	45.00	45.00	45.00	2				1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00			2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2						2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2						2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2						2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2																																				2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2						2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2																					2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2					
H8145	006	0	1	09	04	H8145_006_0	4	2				2				1	55.00	55.00	55.00	2				1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00			2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2						2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2						2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2						2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2																																				2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2						2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2																					2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2					
H8145	042	0	1	09	04	H8145_042_0	4	2				2				1	50.00	50.00	50.00	2				1	2	750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00			2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2						2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2						2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2						2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2																																				2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2						2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2																					2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2					
H8145	052	0	1	09	04	H8145_052_0	4	2				2				1	45.00	45.00	45.00	2				2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00			4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00																		4	2	2	3		2				1	0.00	0.00	0.00																																	2								2					2		3															3															4	2	4	3		2				1	0.00	0.00	0.00			3																																													3															3																														4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00		
H8145	069	0	1	09	04	H8145_069_0	6	2				2				1	40.00	40.00	40.00	2				1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00			2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2						2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2						2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2																																																			2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2						2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2																					2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2					
H8145	091	0	1	09	04	H8145_091_0	4	2				2				1	35.00	35.00	35.00	2				1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00			2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2						2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2						2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2																																																			2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2						2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2																					2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2					
H8145	126	0	1	09	04	H8145_126_0	4	2				2				1	40.00	40.00	40.00	2				1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00			2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2						2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2						2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2						2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2																																				2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2						2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2																					2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2					
H8166	003	0	1	04	01	H8166_003_0	7	2				2				1	10.00	10.00	10.00	2		2	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	40	40	40	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	40	40	40	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	40	40	40	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	40	40	40	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	40	40	40	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	40	40	40	2				2	2																2	2	2	3		1	40	40	40	2				2	2
H8166	005	0	1	04	01	H8166_005_0	11	2				2				1	70.00	70.00	70.00	2		2	2	1	2	750.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H8166	006	0	1	04	01	H8166_006_0	10	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years. Relining and rebasing is eligible once in a 3 year period.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.   Crowns, inlays, onlays and bridge repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.  Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H8166	007	0	1	04	01	H8166_007_0	11	2				2				1	55.00	55.00	55.00	2		2	2																																																																																																																																																																																																																																																																																						
H8166	801	0	1	04	01	H8166_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8166	802	0	1	04	01	H8166_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8166	803	0	1	04	01	H8166_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8166	804	0	1	04	01	H8166_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8171	001	0	1	20	08	H8171_001_0	5																																																																																																																																																																																																																																																																																																						
H8171	002	0	1	20	08	H8171_002_0	5																																																																																																																																																																																																																																																																																																						
H8173	001	0	1	01	01	H8173_001_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8173	005	0	1	01	01	H8173_005_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8173	007	0	1	01	01	H8173_007_0	5	2				2				1	60.00	60.00	60.00	2		1	2	1		750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H8173	011	0	1	01	01	H8173_011_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8173	013	0	1	01	01	H8173_013_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H8173	014	0	1	01	01	H8173_014_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8173	019	0	1	01	01	H8173_019_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H8173	020	0	1	01	01	H8173_020_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8173	021	0	1	01	01	H8173_021_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8173	022	0	1	01	01	H8173_022_0	5	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8173	023	0	1	01	01	H8173_023_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8173	025	0	1	01	01	H8173_025_0	5	2				1	30	30	30	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8173	027	0	1	01	01	H8173_027_0	5	2				1	30	30	30	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8176	004	1	1	01	01	H8176_004_1	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set full, partial, or immediate every 3 yrs	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H8176	004	2	1	01	01	H8176_004_2	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3				2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set full, partial, or immediate every 3 yrs	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H8181	002	0	1	04	01	H8181_002_0	9	2				2				1	50.00	50.00	50.00	2		2	2	1	2	250.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2																																																																																																																																																																					
H8181	004	0	1	04	01	H8181_004_0	7	2				2				1	45.00	45.00	45.00	2		2	2	1	2	600.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2																																																																																																																																																																					
H8181	801	0	1	04	01	H8181_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8181	802	0	1	04	01	H8181_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8181	803	0	1	04	01	H8181_803_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8181	804	0	1	04	01	H8181_804_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8189	001	0	1	02	01	H8189_001_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H8189	007	0	1	02	01	H8189_007_0	5	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H8189	008	0	1	02	01	H8189_008_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H8211	001	0	1	04	01	H8211_001_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8211	005	0	1	04	01	H8211_005_0	2	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8211	006	0	1	04	01	H8211_006_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8211	011	0	1	04	01	H8211_011_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8211	801	0	1	04	01	H8211_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8212	001	0	1	01	01	H8212_001_0	7	2				2				2				2		2	2	2							2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		2500.00	3		2		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Pre and post-op radiographs required. Prior authorization required. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 months. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H8261	001	0	1	20	08	H8261_001_0	1																																																																																																																																																																																																																																																																																																						
H8261	002	0	1	20	08	H8261_002_0	1																																																																																																																																																																																																																																																																																																						
H8267	001	0	1	04	01	H8267_001_0	3	2				2				1	30.00	30.00	30.00	2		2	2	1	2	500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year. One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																				
H8267	002	0	1	04	01	H8267_002_0	3	2				2				1	30.00	30.00	30.00	2		2	2	1	2	500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year. One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																				
H8267	003	0	1	04	01	H8267_003_0	2	2				2				1	35.00	35.00	35.00	2		2	2	1	2	500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year. One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																				
H8267	004	0	1	04	01	H8267_004_0	3	2				2				1	30.00	30.00	30.00	2		2	2	1	2	500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year. One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																				
H8267	005	0	1	04	01	H8267_005_0	4	2				2				1	30.00	30.00	30.00	2		2	2	1	2	500.00	3		2		2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year. One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																				
H8298	001	0	1	01	01	H8298_001_0	10	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8298	002	0	1	01	01	H8298_002_0	7	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		1500.00	3		2		2					2		2	2	1	4		1	50	50	50	2				2	2	2	2	1	1		1	50	50	50	2				2	2	2	2	4	3		1	20	20	20	2				2	2																																																													2	2	1	3		1	50	50	50	2				2	2																														
H8320	001	0	1	04	01	H8320_001_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8320	002	0	1	04	01	H8320_002_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H8320	003	0	1	04	01	H8320_003_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8320	004	0	1	04	01	H8320_004_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H8320	005	0	1	04	01	H8320_005_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8320	006	0	1	04	01	H8320_006_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H8320	011	0	1	04	01	H8320_011_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8320	012	0	1	04	01	H8320_012_0	5	2				1	30	30	30	2				2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8320	013	0	1	04	01	H8320_013_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8320	014	0	1	04	01	H8320_014_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8320	015	0	1	04	01	H8320_015_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8320	016	0	1	04	01	H8320_016_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8320	017	0	1	04	01	H8320_017_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8320	018	0	1	04	01	H8320_018_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8320	019	0	1	04	01	H8320_019_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8320	020	0	1	04	01	H8320_020_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8330	001	0	1	01	01	H8330_001_0	7	2				1	20	20	20	2				2		1	1	2							2				2					2					2		2	2	2	6	2 periodic and 2 limited oral exams per year. 1 comprehensive and 1 periodontal exam per year.	2				2				2	2	2	2	1	6	1 intraoral, panoramic and tomosynthesis comprehensive exam every 3  years. 2 bitewing (1-4 images or tomosynthesis) per year. 1 Intraoral-periapical per day. Cone beam CT (1 per 36 months).	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	5		2				2				2	2	2	2	1	6	2 application of caries per lifetime.	2				2				2	2	2								2					2		2	2	1	6	1 filling per calendar year, per tooth same surface.Crowns, core, post, pins covered once per tooth per 60 months.	2				2				2	2	2	2	1	6	Root canals, bone graft in conjunction with periradicular surgery, tissue regeneration and apicoectomy; each covered once per lifetime, same tooth.	2				2				2	2	2	2	1	6	Periodontal scaling, root planing, occeous surgery & gingivectomy/gingivoplasty 1 per 3 yrs. Gingival flap procedure 1/quadrant per 36 mths. Scaling in prsnce of generalized inflammation 2 per yr, periodontal maint'ce 1 per 12 mths, bone replacement graft & guided tissue regen 1/lifetime per tooth.	2				2				2	2	2	2	1	6	Complete dentures covered once per 60 months. Partial dentures covered once per 84 months. Rebase or reline dentures covered once per 36 months. Replace missing or broken teeth-complete denture covered 3 per 12 months.	2				2				2	2																															2	2	1	6	Pontics and retainers covered once per tooth, per 60 months.	2				2				2	2	2	2	1	6	Coronectomy, frenectomy and frenuloplasty- 1 per lifetime. Alveoloplasty- once per 6 months per quadrant. F Bone replacement graft- 1 per lifetime, same quadrant. Sinus augmentation- 2 per lifetime. Guided tissue regeneration- 1 per 60 months, same tooth	2				2				2	2																2	2	1	6	Occlusal guards covered once per 36 months.	2				2				2	2
H8330	002	0	1	01	01	H8330_002_0	7	2				1	20	20	20	2				2		1	1	2							2				2					2					2		2	2	2	6	2 periodic and 2 limited oral exams per year. 1 comprehensive and 1 periodontal exam per year.	2				2				2	2	2	2	1	6	1 intraoral, panoramic and tomosynthesis comprehensive exam every 3  years. 2 bitewing (1-4 images or tomosynthesis) per year. 1 Intraoral-periapical per day. Cone beam CT (1 per 36 months).	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	5		2				2				2	2	2	2	1	6	2 application of caries per lifetime.	2				2				2	2	2								2					2		2	2	1	6	1 filling per calendar year, per tooth same surface.Crowns, core, post, pins covered once per tooth per 60 months.	2				2				2	2	2	2	1	6	Root canals, bone graft in conjunction with periradicular surgery, tissue regeneration and apicoectomy; each covered once per lifetime, same tooth.	2				2				2	2	2	2	1	6	Periodontal scaling, root planing, occeous surgery & gingivectomy/gingivoplasty 1 per 3 yrs. Gingival flap procedure 1/quadrant per 36 mths. Scaling in prsnce of generalized inflammation 2 per yr, periodontal maint'ce 1 per 12 mths, bone replacement graft & guided tissue regen 1/lifetime per tooth.	2				2				2	2	2	2	1	6	Complete dentures covered once per 60 months. Partial dentures covered once per 84 months. Rebase or reline dentures covered once per 36 months. Replace missing or broken teeth-complete denture covered 3 per 12 months.	2				2				2	2																															2	2	1	6	Pontics and retainers covered once per tooth, per 60 months.	2				2				2	2	2	2	1	6	Coronectomy, frenectomy and frenuloplasty- 1 per lifetime. Alveoloplasty- once per 6 months per quadrant. F Bone replacement graft- 1 per lifetime, same quadrant. Sinus augmentation- 2 per lifetime. Guided tissue regeneration- 1 per 60 months, same tooth	2				2				2	2																2	2	1	6	Occlusal guards covered once per 36 months.	2				2				2	2
H8332	004	0	1	01	01	H8332_004_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8332	007	0	1	01	01	H8332_007_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8332	008	0	1	01	01	H8332_008_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8332	009	0	1	01	01	H8332_009_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8332	010	0	1	01	01	H8332_010_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2		2					2		2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2	2	2	4	6	See Notes	1	50	50	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8332	801	0	1	01	01	H8332_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8379	001	0	1	01	01	H8379_001_0	3	2				3		0	35	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2																																2	2	2	3		2				2				2	2																																																													2	2	1	3		2				2				2	2																														
H8379	003	1	1	01	01	H8379_003_1	4	2				3		0	35	2				2		1	2																																																																																																																																																																																																																																																																																						
H8379	003	2	1	01	01	H8379_003_2	4	2				3		0	35	2				2		1	2																																																																																																																																																																																																																																																																																						
H8379	003	3	1	01	01	H8379_003_3	4	2				3		0	35	2				2		1	2																																																																																																																																																																																																																																																																																						
H8379	003	4	1	01	01	H8379_003_4	4	2				3		0	35	2				2		1	2																																																																																																																																																																																																																																																																																						
H8385	005	0	1	04	01	H8385_005_0	11	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																																																																																																																																																																																				
H8385	006	0	1	04	01	H8385_006_0	11	2				2				1	45.00	45.00	45.00	2		2	2	2							2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																1	2	2	500.00	3		2		2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2
H8421	001	0	1	20	08	H8421_001_0	3																																																																																																																																																																																																																																																																																																						
H8421	002	0	1	20	08	H8421_002_0	3																																																																																																																																																																																																																																																																																																						
H8424	001	0	1	20	08	H8424_001_0	1																																																																																																																																																																																																																																																																																																						
H8424	002	0	1	20	08	H8424_002_0	1																																																																																																																																																																																																																																																																																																						
H8432	009	0	1	02	01	H8432_009_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every 5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H8432	010	0	1	01	01	H8432_010_0	6	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																						
H8432	011	0	1	01	01	H8432_011_0	6	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																						
H8432	040	0	1	02	01	H8432_040_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H8432	042	0	1	01	01	H8432_042_0	6	2				1	20	20	20	2				2		1	1	2							2				2					2					2		2	2	3	6	For limited, Periodic and ComprehensiveLimited oral evaluation: 2 every 12 monthsComprehensive oral evaluation: 1 per lifetimeOral evaluation, problem focused: 3 every 12 months, by reportPeriodic Oral evaluation: 1 every 6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral, complete series: 1 every 36 monthsIntraoral, periapical: 3 every 6 monthsIntraoral, periapical: 6 times every 12 monthsPanoramic Radiographic image: 1 every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Cone beam CT capture and interpretation: 1 every 60 months	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	With varnish: 1 every 3 monthsExcluding varnish: 1 every 6 monthsOnly covered for members under 21 or special approval due to salivary gland damage from surgery, radiation, or disease	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Tobacco counseling, control prevention oral disease: 1 every six monthsUnspecified preventive procedure, by report	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Amalgam / Resin based composites: 1 per tooth, every 24 monthsCrown services: 1 per tooth, every 60 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic Services: 1 per tooth, per lifetime	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Gingivectomy or gingivopIasty: 1 every 12 months, per quadCrown lengthening: 1 per tooth per lifetimePeriodontal scaling and root planning: 1 every 24 months per site/quadOther Periodontics: every 6 to 36 months	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Complete /Partial denture: 1 every 96 months, per archDenture Adjustment: 4 every 12 months, per arch	2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	6	Implants: once per tooth per lifetimeImplant scaling repair: once per 12 monthsImplant replacements/rebond/debridement: once per tooth 24 monthsImplant abutments: once per tooth per 96 monthsAll implant services require prior authorization	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics -Once every 60 months, per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	1 per tooth per lifetime  Other Oral and Maxillofacial Surgery by report	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Limited to members who exhibit a sever physically handicapping malocclusion	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Office visit, observation: 4 every 12 monthsOcclusal guard: 1 every 12 months	2				1	0.00	0.00	0.00	1	2
H8432	043	0	1	01	01	H8432_043_0	6	2				1	20	20	20	2				2		1	1	2							2				2					2					2		2	2	3	6	For limited, Periodic and ComprehensiveLimited oral evaluation: 2 every 12 monthsComprehensive oral evaluation: 1 per lifetimeOral evaluation, problem focused: 3 every 12 months, by reportPeriodic Oral evaluation: 1 every 6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral, complete series: 1 every 36 monthsIntraoral, periapical: 3 every 6 monthsIntraoral, periapical: 6 times every 12 monthsPanoramic Radiographic image: 1 every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Cone beam CT capture and interpretation: 1 every 60 months	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	With varnish: 1 every 3 monthsExcluding varnish: 1 every 6 months Only covered for members under 21 or special approval due to salivary gland damage from surgery, radiation, or disease	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Tobacco counseling, control prevention oral disease: 1 every six monthsUnspecified preventive procedure, by report	2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	1	6	Amalgam / Resin based composites: 1 per tooth, every 24 monthsCrown services: 1 per tooth, every 60 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic Services: 1 per tooth, per lifetime	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Gingivectomy or gingivopIasty: 1 every 12 months, per quad Crown lengthening: 1 per tooth per lifetimePeriodontal scaling and root planning: 1 every 24 months per site/quadOther Periodontics every 6 to 36 months	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Complete /Partial denture: 1 every 96 months, per archDenture Adjustment: 4 every 12 months, per arch	2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	6	Implants: once per tooth per lifetimeImplant scaling repair: once per 12 monthsImplant replacements/rebond/debridement: once per tooth 24 monthsImplant abutments: once per tooth per 96 monthsAll implant services require prior authorization	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics -Once every 60 months, per tooth.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	1 per tooth per lifetimeOther Oral and Maxillofacial Surgery by report	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Limited to members who exhibit a sever physically handicapping malocclusion	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Office visit, observation: 4 every 12 monthsOcclusal guard: 1 every 12 months	2				1	0.00	0.00	0.00	1	2
H8432	804	0	1	01	01	H8432_804_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8432	805	0	1	01	01	H8432_805_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8432	806	0	2	01	01	H8432_806_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8432	811	0	2	01	01	H8432_811_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8432	813	0	1	01	01	H8432_813_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8432	816	0	2	01	01	H8432_816_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8457	001	0	1	01	01	H8457_001_0	7	2				1	20	20	20	2				2		1	2	1		2850.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8481	001	0	1	04	01	H8481_001_0	8	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2								2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	7	6	Deep Cleaning/Root Planing: 1 per quadrant every 24 months (Up to 4 total for 4 quadrants in mouth).  Full Mouth Debridement: 1 every 3 calendar years Therapeutic Cleaning  Gum Inflammation: 2 per calendar year. The 2 cleaning service total is shared with the 16b4 benefit.	2				1	0.00	0.00	0.00	2	2	2	2	10	6	Immediate upper complete denture - 1 per lifetime Immediate lower complete denture - 1 /lifetime Upper partial/denture - 1  every 5 years Lower partial/denture - 1 every 5 years Upper partial/denture adjustments /repairs - 2 per calendar year Lower partial/denture adjustments /repairs - 2 per year	2				1	0.00	0.00	0.00	2	2																																														2	2	5	6	Extractions (simple & surgical): 4 per calendar year.  Removal of Impacted Tooth: 1 per tooth per lifetime	2				1	0.00	0.00	0.00	2	2																														
H8492	001	0	1	01	01	H8492_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8492	002	0	1	01	01	H8492_002_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8554	801	0	1	01	01	H8554_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8573	001	0	1	20	08	H8573_001_0	1																																																																																																																																																																																																																																																																																																						
H8573	002	0	1	20	08	H8573_002_0	1																																																																																																																																																																																																																																																																																																						
H8578	001	0	1	01	01	H8578_001_0	3	2				2				3		35.00	250.00	2		1	2	1		550.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	003	0	1	01	01	H8578_003_0	2	2				2				3		20.00	200.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	004	0	1	01	01	H8578_004_0	3	2				2				3		40.00	325.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	009	0	1	01	01	H8578_009_0	2	2				2				3		40.00	450.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	012	0	1	01	01	H8578_012_0	3	2				2				3		50.00	450.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	019	0	1	01	01	H8578_019_0	5	2				2				3		40.00	350.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	024	0	1	01	01	H8578_024_0	3	2				2				3		50.00	450.00	2		1	2	1		500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	801	0	1	02	01	H8578_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8578	802	0	1	02	01	H8578_802_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8578	803	0	1	02	01	H8578_803_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8597	001	0	1	01	01	H8597_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8597	002	0	1	01	01	H8597_002_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8597	003	0	1	01	01	H8597_003_0	3	2				1	20	20	20	2				2		1	2	1		500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8597	004	0	1	01	01	H8597_004_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8597	005	0	1	01	01	H8597_005_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8597	006	0	1	01	01	H8597_006_0	3	2				1	20	20	20	2				2		1	2	1		500.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8604	014	1	1	04	01	H8604_014_1	7	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1000.00	3				2					2		4	2	1	6	One Filling per tooth every three years.One Crown per tooth every five years.	2				2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	2				2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.Periodontal maintenance - two every calendar year.Full mouth debridement - one every three calendar years.	2				2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	2				2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	2				2				2	2	4	1				2				2				2	2																														
H8604	014	2	1	04	01	H8604_014_2	7	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1000.00	3				2					2		4	2	1	6	One Filling per tooth every three years.One Crown per tooth every five years.	2				2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	2				2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.Periodontal maintenance - two every calendar year.Full mouth debridement - one every three calendar years.	2				2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	2				2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	2				2				2	2	4	1				2				2				2	2																														
H8604	015	0	1	04	01	H8604_015_0	7	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1000.00	3		2		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	2				2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	2				2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	2				2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	2				2				2	2																															4	2	1	6	One crown per tooth every five calendar years	2				2				2	2	4	1				2				2				2	2																														
H8604	801	0	1	04	01	H8604_801_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8614	001	0	1	20	08	H8614_001_0	1																																																																																																																																																																																																																																																																																																						
H8614	002	0	1	20	08	H8614_002_0	1																																																																																																																																																																																																																																																																																																						
H8634	801	0	1	04	01	H8634_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8634	805	0	1	04	01	H8634_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8634	807	0	1	04	01	H8634_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8634	813	0	1	04	01	H8634_813_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8634	815	0	1	04	01	H8634_815_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8634	821	0	1	04	01	H8634_821_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8634	824	0	1	04	01	H8634_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8649	010	0	1	01	01	H8649_010_0	3	2				1	20	20	20	2				2		1	2	1		2750.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8649	013	0	1	01	01	H8649_013_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H8649	801	0	1	01	01	H8649_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8649	803	0	1	01	01	H8649_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8649	805	0	1	01	01	H8649_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8655	004	0	1	20	08	H8655_004_0	1																																																																																																																																																																																																																																																																																																						
H8655	005	0	1	20	08	H8655_005_0	1																																																																																																																																																																																																																																																																																																						
H8711	801	0	1	04	01	H8711_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H8764	001	0	1	01	01	H8764_001_0	7	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H8764	002	0	1	02	01	H8764_002_0	7	2				2				1	20.00	20.00	20.00	2		1	2																																																																																																																																																																																																																																																																																						
H8764	003	0	1	01	01	H8764_003_0	7	2				2				1	45.00	45.00	45.00	2		1	2																																																																																																																																																																																																																																																																																						
H8764	004	0	1	01	01	H8764_004_0	7	2				2				1	50.00	50.00	50.00	2		1	2																																																																																																																																																																																																																																																																																						
H8764	801	0	1	02	01	H8764_801_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8768	005	0	1	04	01	H8768_005_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	007	0	1	04	01	H8768_007_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	008	0	1	04	01	H8768_008_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	009	0	1	04	01	H8768_009_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	010	0	1	04	01	H8768_010_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	011	0	1	04	01	H8768_011_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	013	0	1	04	01	H8768_013_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	016	0	1	04	01	H8768_016_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	017	1	1	04	01	H8768_017_1	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	017	2	1	04	01	H8768_017_2	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	018	0	1	04	01	H8768_018_0	3	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	019	0	1	04	01	H8768_019_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	020	0	1	04	01	H8768_020_0	3	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	021	0	1	04	01	H8768_021_0	3	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	022	0	1	04	01	H8768_022_0	6	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	023	0	1	04	01	H8768_023_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8768	024	0	1	04	01	H8768_024_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	025	0	1	04	01	H8768_025_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	027	0	1	04	01	H8768_027_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	028	0	1	04	01	H8768_028_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	030	0	1	04	01	H8768_030_0	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	031	0	1	04	01	H8768_031_0	3	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	034	0	1	04	01	H8768_034_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8768	035	0	1	04	01	H8768_035_0	6	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	039	0	1	04	01	H8768_039_0	6	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	040	0	1	04	01	H8768_040_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8768	045	0	1	04	01	H8768_045_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	046	0	1	04	01	H8768_046_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	048	0	1	04	01	H8768_048_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2
H8768	055	1	1	04	01	H8768_055_1	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	055	2	1	04	01	H8768_055_2	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8768	058	0	1	04	01	H8768_058_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8768	059	0	1	04	01	H8768_059_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8768	061	0	1	04	01	H8768_061_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	063	0	1	04	01	H8768_063_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	064	0	1	04	01	H8768_064_0	5	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H8768	801	0	1	04	01	H8768_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H8769	001	0	1	20	08	H8769_001_0	1																																																																																																																																																																																																																																																																																																						
H8769	002	0	1	20	08	H8769_002_0	1																																																																																																																																																																																																																																																																																																						
H8777	001	0	1	20	08	H8777_001_0	1																																																																																																																																																																																																																																																																																																						
H8777	002	0	1	20	08	H8777_002_0	1																																																																																																																																																																																																																																																																																																						
H8794	001	0	1	01	01	H8794_001_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	002	0	1	01	01	H8794_002_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	006	0	1	01	01	H8794_006_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	007	0	1	01	01	H8794_007_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	009	0	1	01	01	H8794_009_0	7	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	010	0	1	01	01	H8794_010_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	011	0	1	01	01	H8794_011_0	6	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	016	0	1	01	01	H8794_016_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	017	0	1	01	01	H8794_017_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	018	0	1	01	01	H8794_018_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	019	0	1	01	01	H8794_019_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	020	0	1	01	01	H8794_020_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	021	0	1	01	01	H8794_021_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	022	0	1	01	01	H8794_022_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	023	0	1	01	01	H8794_023_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	024	0	1	01	01	H8794_024_0	5	2				2				3		0.00	5.00	2		1	1																																																																																																																																																																																																																																																																																						
H8794	025	0	1	01	01	H8794_025_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																						
H8797	001	0	1	01	01	H8797_001_0	10	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H8797	003	0	1	02	01	H8797_003_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3500.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8797	004	0	1	02	01	H8797_004_0	9	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		9000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8800	001	0	1	20	08	H8800_001_0	1																																																																																																																																																																																																																																																																																																						
H8800	002	0	1	20	08	H8800_002_0	1																																																																																																																																																																																																																																																																																																						
H8811	001	0	1	20	08	H8811_001_0	1																																																																																																																																																																																																																																																																																																						
H8811	002	0	1	20	08	H8811_002_0	1																																																																																																																																																																																																																																																																																																						
H8832	001	0	1	04	01	H8832_001_0	9	2				2				2				2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																1	1							2					2		4	1				2				2				1	2	4	1				2				2				1	2	4	1				2				2				1	2	4	1				2				2				1	2																															4	1				2				2				1	2	4	1				2				2				1	2																														
H8832	002	0	1	04	01	H8832_002_0	9	2				2				2				2		1	2																																																																																																																																																																																																																																																																																						
H8832	004	0	1	04	01	H8832_004_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																1	2	2	175.00	5		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H8832	005	0	1	04	01	H8832_005_0	7	2				2				2				2		1	2																																																																																																																																																																																																																																																																																						
H8832	801	0	1	04	01	H8832_801_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H8832	802	0	1	04	01	H8832_802_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H8832	803	0	1	04	01	H8832_803_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H8832	804	0	1	04	01	H8832_804_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H8845	001	0	1	01	01	H8845_001_0	7	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		5000.00	3		2		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H8849	001	0	1	02	01	H8849_001_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	003	0	1	02	01	H8849_003_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		1800.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	005	0	1	02	01	H8849_005_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		1000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	006	0	1	02	01	H8849_006_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H8849	009	0	1	02	01	H8849_009_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		3250.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H8849	015	0	1	01	01	H8849_015_0	5	2				1	20	20	20	2				2		1	2	1		3500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	016	0	1	01	01	H8849_016_0	4	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	017	0	1	01	01	H8849_017_0	5	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	018	1	1	01	01	H8849_018_1	4	2				1	20	20	20	2				2		1	2	1		3750.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	018	2	1	01	01	H8849_018_2	4	2				1	20	20	20	2				2		1	2	1		4500.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	018	3	1	01	01	H8849_018_3	4	2				1	20	20	20	2				2		1	2	1		4250.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	018	4	1	01	01	H8849_018_4	4	2				1	20	20	20	2				2		1	2	1		3500.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	019	1	1	01	01	H8849_019_1	4	2				1	20	20	20	2				2		1	2	1		3250.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	019	2	1	01	01	H8849_019_2	4	2				1	20	20	20	2				2		1	2	1		4000.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	019	3	1	01	01	H8849_019_3	4	2				1	20	20	20	2				2		1	2	1		3750.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	019	4	1	01	01	H8849_019_4	4	2				1	20	20	20	2				2		1	2	1		2750.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	020	1	1	01	01	H8849_020_1	4	2				1	20	20	20	2				2		1	2	1		3000.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	020	2	1	01	01	H8849_020_2	4	2				1	20	20	20	2				2		1	2	1		2250.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	020	3	1	01	01	H8849_020_3	5	2				1	20	20	20	2				2		1	2	1		2750.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	020	4	1	01	01	H8849_020_4	4	2				1	20	20	20	2				2		1	2	1		2750.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	021	0	1	01	01	H8849_021_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	022	0	1	01	01	H8849_022_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	023	0	1	01	01	H8849_023_0	4	2				1	20	20	20	2				2		1	2	1		4500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	024	1	1	01	01	H8849_024_1	4	2				1	20	20	20	2				2		1	2	1		3750.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	024	2	1	01	01	H8849_024_2	4	2				1	20	20	20	2				2		1	2	1		5500.00	3				2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	025	0	1	01	01	H8849_025_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	026	0	1	01	01	H8849_026_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	027	0	1	01	01	H8849_027_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	028	0	1	01	01	H8849_028_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	029	0	1	01	01	H8849_029_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	030	0	1	01	01	H8849_030_0	4	2				1	20	20	20	2				2		1	2	1		2250.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	031	0	1	01	01	H8849_031_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	032	0	1	02	01	H8849_032_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H8854	002	0	1	01	01	H8854_002_0	10	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	1	6	Frequency varies based on service.	2				2				2	2	2	2	1	6	Bitewing: once every 12 months Periapical: As neededPanoramic: once every 36 months Occlusal: As neededVertical bitewings: once every 36 months Intraoral Imaging: once every 36 months	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3000.00	3		2		2					2		2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Frequencies vary based on service.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Frequency varies by service.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	one tooth per lifetime	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Frequencies vary by service	2				1	0.00	0.00	0.00	2	2
H8879	001	0	1	02	01	H8879_001_0	10	2				2				3		0.00	30.00	2		2	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8889	002	0	1	04	01	H8889_002_0	4	2				2				3		0.00	60.00	2		2	2	1	2	800.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.  Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per plan year to unlimited.	1	50	50	50	2				2	2
H8889	009	0	1	04	01	H8889_009_0	2	2				2				3		0.00	50.00	2		2	2	1	2	1500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	012	0	1	04	01	H8889_012_0	3	2				2				3		0.00	50.00	2		2	2	1	2	700.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	013	0	1	04	01	H8889_013_0	3	2				2				3		0.00	20.00	2		2	2	1	2	1000.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	014	0	1	04	01	H8889_014_0	3	2				2				3		0.00	50.00	2		2	2	1	2	500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	016	0	1	04	01	H8889_016_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8889	019	1	1	04	01	H8889_019_1	3	2				2				3		0.00	75.00	2		2	2	1	2	1100.00	3				2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	019	2	1	04	01	H8889_019_2	3	2				2				3		0.00	75.00	2		2	2	1	2	500.00	3				2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	020	1	1	04	01	H8889_020_1	3	2				2				3		0.00	60.00	2		2	2	1	2	1000.00	3				2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	12	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	020	2	1	04	01	H8889_020_2	3	2				2				3		0.00	60.00	2		2	2	1	2	700.00	3				2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	021	1	1	04	01	H8889_021_1	3	2				2				3		0.00	20.00	2		2	2	1	2	1200.00	3				2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	021	2	1	04	01	H8889_021_2	3	2				2				3		0.00	20.00	2		2	2	1	2	1200.00	3				2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	022	0	1	04	01	H8889_022_0	5	2				2				3		0.00	75.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	6	Periodicity varies by service ranging from 2 per year or 1 per year.	2				2				2	2																																																																																																																																																																					
H8889	023	0	1	04	01	H8889_023_0	5	2				2				3		0.00	75.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	6	Periodicity varies by service ranging from 2 per year or 1 per year.	2				2				2	2																																																																																																																																																																					
H8889	024	0	1	04	01	H8889_024_0	3	2				2				3		0.00	60.00	2		2	2	1	2	500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	025	0	1	04	01	H8889_025_0	8	2				2				3		0.00	75.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	6	Periodicity varies by service ranging from 2 per year or 1 per year.	2				2				2	2																																																																																																																																																																					
H8889	026	0	1	04	01	H8889_026_0	3	2				2				3		0.00	60.00	2		2	2	1	2	500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	027	1	1	04	01	H8889_027_1	6	2				2				3		0.00	75.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	6	Periodicity varies by service ranging from 2 per year or 1 per year.	2				2				2	2																																																																																																																																																																					
H8889	027	2	1	04	01	H8889_027_2	5	2				2				3		0.00	75.00	2		2	2	2							2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 1 every year.	2				2				2	2																2	2	2	3		2				2				2	2																2	2	1	6	Periodicity varies by service ranging from 2 per year or 1 per year.	2				2				2	2																																																																																																																																																																					
H8889	028	1	1	04	01	H8889_028_1	5	2				2				3		0.00	60.00	2		2	2	1	2	600.00	3				2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	028	2	1	04	01	H8889_028_2	5	2				2				3		0.00	60.00	2		2	2	1	2	600.00	3				2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	029	1	1	04	01	H8889_029_1	3	2				2				3		0.00	20.00	2		2	2	1	2	700.00	3				2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	029	2	1	04	01	H8889_029_2	3	2				2				3		0.00	20.00	2		2	2	1	2	700.00	3				2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H8889	801	0	1	04	01	H8889_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H8894	001	0	1	01	01	H8894_001_0	6	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H8902	002	0	1	01	01	H8902_002_0	11	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H8902	010	0	1	01	01	H8902_010_0	11	2				2				2				2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H8902	012	0	1	01	01	H8902_012_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3500.00	3		2		2					2		2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																															2	1				1	25	25	25	2				1	2	2	1				1	25	25	25	2				1	2																2	1				1	25	25	25	2				1	2
H8902	013	0	1	01	01	H8902_013_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings:  1 set per 12 monthsComprehensive Series / Panoramic: 1 per 36 months	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H8902	801	0	1	01	01	H8902_801_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H8902	802	0	1	01	01	H8902_802_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H8902	803	0	1	01	01	H8902_803_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H8902	804	0	1	01	01	H8902_804_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H8908	004	0	1	02	01	H8908_004_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H8908	005	0	1	01	01	H8908_005_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	3	2		2				1	0.00	0.00	0.00	1	2																2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
H8908	007	0	1	01	01	H8908_007_0	4	2				1	20	20	20	2				2		1	2	1		1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H8908	801	0	1	01	01	H8908_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H8908	802	0	1	01	01	H8908_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H8908	804	0	1	01	01	H8908_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H8908	805	0	1	01	01	H8908_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H8917	001	0	1	04	01	H8917_001_0	7	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H8917	002	0	1	04	01	H8917_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		1	2	2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H8917	005	0	1	04	01	H8917_005_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8917	006	0	1	04	01	H8917_006_0	5	2				1	30	30	30	2				2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8928	001	0	1	01	01	H8928_001_0	7	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	6	Visit limit for each service every year.	2				2				2	2	2	2	1	6	Bitewings (one, two, three, four images), intraoral tomosynthesis (bitewing radiographic image): 1 per calendar year. Intraoral tomosynthesis (periapical radiographic image): 8 per calendar year.	2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	Inlays, Onlays, Crowns including core buildup, pins, post and core-1 per tooth per 60 months	2				2				1	2	2	2	1	6	Root canal therapy, anterior, premolar, molar: 1 per tooth per lifetime.	2				2				1	2	2	2	1	6	Periodontal maintenance-2 per 12 months following periodontal therapyPeriodontal scaling and root planing-1 per quadrant per 24 monthsGingevectomy/gingivoplasty once per quadrant per 36 months.	2				2				1	2	2	2	1	6	Removable dentures (complete, partial, immediate): 1 per 60 months. Adjustments: 1 per 6 months. Repair, replace teeth: 3 per 60 months. Replace all teeth, rebase, reline, soft liner, metal substructure: 1 per 12 months.	2				2				1	2																2	2	1	6	Dental implants covered 1 every sixty months, per tooth per member. Limit of two implants per calendar year per member.	2				2				1	2	2	2	1	6	Fixed partial dentures:  Pontics (resin, base metal, noble metal, porcelain or titanium), inlays, onlays, crowns and retainers: 1 per tooth per 60 months.  Recement or re-bond fixed partial denture: once per 60 months.	2				2				1	2	2	1				2				2				1	2																2	1				2				2				2	2
H8928	002	0	1	01	01	H8928_002_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	6	Visit limit for each service every year.	2				2				2	2	2	2	1	6	Bitewings (one, two, three, four images), intraoral tomosynthesis (bitewing radiographic image): 1 per calendar year. Intraoral tomosynthesis (periapical radiographic image): 8 per calendar year.	2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	Inlays, Onlays, Crowns including core buildup, pins, post and core-1 per tooth per 60 months	2				2				1	2	2	2	1	6	Root canal therapy, anterior, premolar, molar: 1 per tooth per lifetime.	2				2				1	2	2	2	1	6	Periodontal maintenance-2 per 12 months following periodontal therapyPeriodontal scaling and root planing-1 per quadrant per 24 monthsGingevectomy/gingivoplasty once per quadrant per 36 months.	2				2				1	2	2	2	1	6	Removable dentures (complete, partial, immediate): 1 per 60 months. Adjustments: 1 per 6 months. Repair, replace teeth: 3 per 60 months. Replace all teeth, rebase, reline, soft liner, metal substructure: 1 per 12 months.	2				2				1	2																2	2	1	6	Dental implants covered 1 every sixty months, per tooth per member. Limit of two implants per calendar year per member.	2				2				1	2	2	2	1	6	Fixed partial dentures:  Pontics (resin, base metal, noble metal, porcelain or titanium), inlays, onlays, crowns and retainers: 1 per tooth per 60 months.  Recement or re-bond fixed partial denture: once per 60 months.	2				2				1	2	2	1				2				2				1	2																2	1				2				2				2	2
H8947	001	1	1	04	01	H8947_001_1	6	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3000.00	3				2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1							2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	001	2	1	04	01	H8947_001_2	8	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3500.00	3				2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1							2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	001	3	1	04	01	H8947_001_3	7	2				2				1	20.00	20.00	20.00	2		2	2	1	2	4500.00	3				2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1							2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	001	4	1	04	01	H8947_001_4	6	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3000.00	3				2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1							2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	002	1	1	04	01	H8947_002_1	7	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3500.00	3				2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1							2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	002	2	1	04	01	H8947_002_2	7	2				2				1	20.00	20.00	20.00	2		2	2	1	2	4000.00	3				2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1							2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	002	3	1	04	01	H8947_002_3	7	2				2				1	20.00	20.00	20.00	2		2	2	1	2	5000.00	3				2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1							2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	002	4	1	04	01	H8947_002_4	6	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3500.00	3				2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1							2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	006	0	1	04	01	H8947_006_0	7	2				1	20	20	20	2				2		2	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1							2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	2				2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	2				2				2	2	2	2	1	6	Periodontal scaling and root planning covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	2				2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	2				2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2
H8982	001	0	1	20	08	H8982_001_0	1																																																																																																																																																																																																																																																																																																						
H8982	003	0	1	20	08	H8982_003_0	1																																																																																																																																																																																																																																																																																																						
H8992	001	0	1	20	08	H8992_001_0	1																																																																																																																																																																																																																																																																																																						
H8992	002	0	1	20	08	H8992_002_0	1																																																																																																																																																																																																																																																																																																						
H9001	030	15	1	01	01	H9001_030_15	6	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	030	16	1	01	01	H9001_030_16	6	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	030	19	1	01	01	H9001_030_19	6	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	031	15	1	01	01	H9001_031_15	6	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	031	16	1	01	01	H9001_031_16	7	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	031	19	1	01	01	H9001_031_19	6	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	031	21	1	01	01	H9001_031_21	7	2				2				1	30.00	30.00	30.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	039	0	1	01	01	H9001_039_0	5	2				2				1	40.00	40.00	40.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	041	15	1	01	01	H9001_041_15	6	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	041	16	1	01	01	H9001_041_16	7	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	041	19	1	01	01	H9001_041_19	6	2				2				1	60.00	60.00	60.00	2		1	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2								2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	803	0	1	01	01	H9001_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9003	001	0	1	02	01	H9003_001_0	7	2				2				1	35.00	35.00	35.00	2		1	1																																																																																																																																																																																																																																																																																						
H9003	006	0	1	02	01	H9003_006_0	7	2				2				1	40.00	40.00	40.00	2		1	1																																																																																																																																																																																																																																																																																						
H9003	008	0	1	02	01	H9003_008_0	9	2				2				1	55.00	55.00	55.00	2		1	1																																																																																																																																																																																																																																																																																						
H9003	009	0	1	02	01	H9003_009_0	7	2				2				1	45.00	45.00	45.00	2		1	1																																																																																																																																																																																																																																																																																						
H9003	801	0	1	01	01	H9003_801_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9003	802	0	1	01	01	H9003_802_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9042	004	0	1	04	01	H9042_004_0	7	2				2				2				2		2	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Cast restorations (including crowns and onlays) and associated procedures (such as cores and substructures) on the same tooth are payable once in any five-year period. Posterior composite resin restorations are covered services.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	6	Every year for periodic maintenance, but note that root planing and scaling is payable once per quadrant in 24 consecutive months. Full mouth debridement is a benefit once in a lifetime.	3		0	50	2				2	2	2	2	1	6	Full and partial dentures are limited to once in a five year period. Relines and Rebase to existing Full and Partial Dentures covered once every 36 months	1	50	50	50	2				2	2																2	2	1	6	1 implant per tooth per 5 year period	1	50	50	50	2				2	2	2	2	1	6	Bridges are covered once in a 5-year period. Relines & repairs to bridges covered once per tooth per 5-year period.	1	50	50	50	2				2	2	2	2	1	6	1 extraction per tooth per lifetime	1	50	50	50	2				2	2																2	1				3		0	50	2				2	2
H9042	007	0	1	04	01	H9042_007_0	8	2				2				2				2		2	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Cast restorations (including crowns and onlays) and associated procedures (such as cores and substructures) on the same tooth are payable once in any five-year period. Posterior composite resin restorations are covered services.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	6	Every year for periodic maintenance, but note that root planing and scaling is payable once per quadrant in 24 consecutive months. Full mouth debridement is a benefit once in a lifetime.	3		0	50	2				2	2	2	2	1	6	Full and partial dentures are limited to once in a five year period. Relines and Rebase to existing Full and Partial Dentures covered once every 36 months.	1	50	50	50	2				2	2																2	2	1	6	1 implant per tooth per 5 year period.	1	50	50	50	2				2	2	2	2	1	6	Bridges are covered once in a 5-year period. Relines & repairs to bridges covered once per tooth per 5-year period.	1	50	50	50	2				2	2	2	2	1	6	1 extraction per tooth per lifetime.	1	50	50	50	2				2	2																2	1				3		0	50	2				2	2
H9042	008	0	1	04	01	H9042_008_0	7	2				2				2				2		2	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1							2					2		2	2	1	6	Cast restorations (including crowns and onlays) and associated procedures (such as cores and substructures) on the same tooth are payable once in any five-year period. Posterior composite resin restorations are covered services.	2				2				2	2	2	1				2				2				2	2	2	2	2	6	Every year for periodic maintenance, but note that root planing and scaling is payable once per quadrant in 24 consecutive months. Full mouth debridement is a benefit once in a lifetime.	2				2				2	2	2	2	1	6	Full and partial dentures are limited to once in a five year period. Relines and Rebase to existing Full and Partial Dentures covered once every 36 months.	2				2				2	2																2	2	1	6	1 implant per tooth per 5 year period	2				2				2	2	2	2	1	6	Bridges are covered once in a 5-year period. Relines & repairs to bridges covered once per tooth per 5-year period.	2				2				2	2	2	2	1	6	1 extraction per tooth per lifetime.	2				2				2	2																2	1				2				2				2	2
H9052	001	0	1	20	08	H9052_001_0	1																																																																																																																																																																																																																																																																																																						
H9052	002	0	1	20	08	H9052_002_0	1																																																																																																																																																																																																																																																																																																						
H9065	001	0	1	01	01	H9065_001_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H9065	002	0	1	02	01	H9065_002_0	5	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																						
H9065	008	0	1	01	01	H9065_008_0	4	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																						
H9065	014	0	1	02	01	H9065_014_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																				
H9065	015	0	1	02	01	H9065_015_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9065	016	0	1	01	01	H9065_016_0	6	2				1	20	20	20	2				2		1	2	1		750.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H9066	001	0	1	01	01	H9066_001_0	4	2				2				2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2								2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H9066	002	0	1	01	01	H9066_002_0	6	2				2				2				2		2	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2								2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H9066	003	0	1	01	01	H9066_003_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2								2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H9068	001	0	1	20	08	H9068_001_0	1																																																																																																																																																																																																																																																																																																						
H9068	002	0	1	20	08	H9068_002_0	1																																																																																																																																																																																																																																																																																																						
H9096	001	0	1	02	01	H9096_001_0	5	2				2				3		0.00	40.00	2		2	2	1		600.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H9096	002	0	1	02	01	H9096_002_0	4	2				2				3		0.00	35.00	2		2	2	1		800.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H9096	004	0	1	01	01	H9096_004_0	5	2				2				3		0.00	75.00	2		2	2	1		500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H9096	005	0	1	01	01	H9096_005_0	5	2				2				3		0.00	20.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H9096	010	0	1	02	01	H9096_010_0	3	2				2				3		0.00	40.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 3 years to 8 every year.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Periodicity varies by service ranging from 2 per year to 1 per year.	2				2				2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per 5 years to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service ranging from 12 per lifetime to 3 per year.	1	50	50	50	2				2	2																																														2	2	1	6	Recement or re-bond fixed partial denture: 1 per 6 months.   Fixed partial denture:  1 every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Periodicity varies by service from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																2	2	1	6	Periodicity varies by service from 2 per year to unlimited.	1	50	50	50	2				2	2
H9096	801	0	1	01	01	H9096_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9096	802	0	1	01	01	H9096_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9096	803	0	1	01	01	H9096_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9096	804	0	1	02	01	H9096_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9096	805	0	1	02	01	H9096_805_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9096	806	0	1	02	01	H9096_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9147	001	0	1	02	01	H9147_001_0	9	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1							2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H9153	001	0	1	01	01	H9153_001_0	5	2				2				2				2		2	2	1		2500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H9179	001	0	1	01	01	H9179_001_0	8	2				2				1	40.00	40.00	40.00	2		2	2	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H9179	002	0	1	01	01	H9179_002_0	7	2				2				1	50.00	50.00	50.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing, or 1 per consecutive 36 months for comprehensive series.	2				2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	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				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H9179	003	0	1	01	01	H9179_003_0	6	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H9179	004	0	1	01	01	H9179_004_0	7	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H9179	801	0	1	01	01	H9179_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9179	802	0	1	01	01	H9179_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9185	001	0	1	20	08	H9185_001_0	1																																																																																																																																																																																																																																																																																																						
H9185	002	0	1	20	08	H9185_002_0	1																																																																																																																																																																																																																																																																																																						
H9191	001	0	1	01	01	H9191_001_0	6	2				1	20	20	20	2				2		1	2	1		5000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9191	006	0	1	01	01	H9191_006_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9191	007	0	1	01	01	H9191_007_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9207	002	0	1	01	01	H9207_002_0	12	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				2	2																														
H9207	004	0	1	01	01	H9207_004_0	11	2				2				2				2		2	2	2							2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	2		5000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H9207	012	0	1	01	01	H9207_012_0	12	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				2	2																														
H9207	015	0	1	01	01	H9207_015_0	12	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				2	2																														
H9207	016	0	1	01	01	H9207_016_0	12	2				2				2				2		2	2	2							2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	1	2		4000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																													
H9207	017	0	1	01	01	H9207_017_0	11	2				2				2				2		2	2	1		550.00	3		1	1	2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H9207	018	0	1	01	01	H9207_018_0	12	2				2				1	40.00	40.00	40.00	2		1	2	1		625.00	3		1	1	2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				2	2																														
H9231	002	0	1	04	01	H9231_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9231	005	0	1	04	01	H9231_005_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9231	006	0	1	04	01	H9231_006_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9231	012	0	1	04	01	H9231_012_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9231	015	0	1	04	01	H9231_015_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9231	018	0	1	04	01	H9231_018_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9231	020	0	1	04	01	H9231_020_0	5	2				1	30	30	30	2				2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9233	801	0	1	04	01	H9233_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9233	802	0	1	04	01	H9233_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9233	803	0	2	04	01	H9233_803_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9233	804	0	2	04	01	H9233_804_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9233	805	0	1	04	01	H9233_805_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9233	806	0	1	04	01	H9233_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9233	807	0	1	04	01	H9233_807_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9233	808	0	1	04	01	H9233_808_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9233	809	0	1	04	01	H9233_809_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9233	810	0	1	04	01	H9233_810_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9233	811	0	1	04	01	H9233_811_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9233	812	0	1	04	01	H9233_812_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9252	001	0	1	20	08	H9252_001_0	1																																																																																																																																																																																																																																																																																																						
H9252	002	0	1	20	08	H9252_002_0	1																																																																																																																																																																																																																																																																																																						
H9266	001	0	1	20	08	H9266_001_0	1																																																																																																																																																																																																																																																																																																						
H9266	003	0	1	20	08	H9266_003_0	1																																																																																																																																																																																																																																																																																																						
H9289	001	0	1	20	08	H9289_001_0	1																																																																																																																																																																																																																																																																																																						
H9289	002	0	1	20	08	H9289_002_0	1																																																																																																																																																																																																																																																																																																						
H9306	003	0	1	01	01	H9306_003_0	2	2				2				1	40.00	40.00	40.00	2		2	2	1		1500.00	3		2		2				2					2					2		2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	o Palliative Treatment of dental pain - once per visito Deep sedation/general anesthesia - first 15 min    o Deep sedation/general anesthesia - each 15 min increment	1	20	20	20	2				1	2
H9306	004	0	1	01	01	H9306_004_0	3	2				1	20	20	20	2				2		2	2	1		1985.00	3		2		2				2					2					2		2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	in notes	2				2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	2				2				1	2	2	2	1	6	in notes	2				2				1	2	2	2	1	6	in notes	2				2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	2				2				1	2																2	2	1	6	o Palliative Treatment of dental pain - once per visito Deep sedation/general anesthesia - first 15 min    o Deep sedation/general anesthesia - each 15 min increment	2				2				1	2
H9306	007	0	1	01	01	H9306_007_0	3	2				2				1	40.00	40.00	40.00	2		2	2	1		1695.00	3		2		2				2					2					2		2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	in notes	2				2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	2				2				1	2	2	2	1	6	in notes	2				2				1	2	2	2	1	6	in notes	2				2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	2				2				1	2																2	2	1	6	o Palliative Treatment of dental pain - once per visito Deep sedation/general anesthesia - first 15 min    o Deep sedation/general anesthesia - each 15 min increment	2				2				1	2
H9306	008	1	1	01	01	H9306_008_1	3	2				2				1	40.00	40.00	40.00	2		2	2	1		3175.00	3				2				2					2					2		2	2	1	6	Oral Exams - Every 6 monthsComprehensive oral exam- every 36 monthsLimited Oral Evaluation - 3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	palliative treatment of dental pain - per visitdeep sedation/general anesthesia - first 15 minutesdeep sedation/general anesthesia-each 15 minute increment	1	20	20	20	2				1	2
H9306	008	2	1	01	01	H9306_008_2	3	2				2				1	40.00	40.00	40.00	2		2	2	1		2850.00	3				2				2					2					2		2	2	1	6	Oral Exams - Every 6 monthsComprehensive oral exam- every 36 monthsLimited Oral Evaluation - 3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	palliative treatment of dental pain - per visitdeep sedation/general anesthesia - first 15 minutesdeep sedation/general anesthesia-each 15 minute increment	1	20	20	20	2				1	2
H9306	009	1	1	01	01	H9306_009_1	3	2				2				1	40.00	40.00	40.00	2		2	2	1		2975.00	3				2				2					2					2		2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	o Palliative Treatment of dental pain - once per visito Deep sedation/general anesthesia - first 15 min    o Deep sedation/general anesthesia - each 15 min increment	1	20	20	20	2				1	2
H9306	009	2	1	01	01	H9306_009_2	3	2				2				1	40.00	40.00	40.00	2		2	2	1		2725.00	3				2				2					2					2		2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1							2					2		2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	o Palliative Treatment of dental pain - once per visito Deep sedation/general anesthesia - first 15 min    o Deep sedation/general anesthesia - each 15 min increment	1	20	20	20	2				1	2
H9314	001	0	1	01	01	H9314_001_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H9317	001	0	1	20	08	H9317_001_0	3																																																																																																																																																																																																																																																																																																						
H9317	002	0	1	20	08	H9317_002_0	3																																																																																																																																																																																																																																																																																																						
H9323	001	0	1	20	08	H9323_001_0	1																																																																																																																																																																																																																																																																																																						
H9323	002	0	1	20	08	H9323_002_0	1																																																																																																																																																																																																																																																																																																						
H9326	001	0	1	04	01	H9326_001_0	7	2				2				1	55.00	55.00	55.00	2		2	2	1	2	625.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H9326	002	0	1	04	01	H9326_002_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1	2	625.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H9326	003	0	1	04	01	H9326_003_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1	2	650.00	3		1	1	2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H9326	801	0	1	04	01	H9326_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9360	001	0	1	20	08	H9360_001_0	1																																																																																																																																																																																																																																																																																																						
H9360	002	0	1	20	08	H9360_002_0	1																																																																																																																																																																																																																																																																																																						
H9364	002	0	1	02	01	H9364_002_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H9364	003	0	1	02	01	H9364_003_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H9411	001	0	1	20	08	H9411_001_0	1																																																																																																																																																																																																																																																																																																						
H9411	004	0	1	20	08	H9411_004_0	1																																																																																																																																																																																																																																																																																																						
H9412	803	0	1	04	01	H9412_803_0	1	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9431	014	0	1	04	01	H9431_014_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
H9431	801	0	1	04	01	H9431_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9438	001	0	1	20	08	H9438_001_0	1																																																																																																																																																																																																																																																																																																						
H9438	002	0	1	20	08	H9438_002_0	1																																																																																																																																																																																																																																																																																																						
H9460	801	0	1	01	01	H9460_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9468	001	0	1	20	08	H9468_001_0	2																																																																																																																																																																																																																																																																																																						
H9468	002	0	1	20	08	H9468_002_0	4																																																																																																																																																																																																																																																																																																						
H9485	801	0	1	04	01	H9485_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9485	802	0	1	04	01	H9485_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9485	803	0	1	04	01	H9485_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9525	004	0	1	02	01	H9525_004_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
H9525	006	0	1	02	01	H9525_006_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	011	0	1	02	01	H9525_011_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H9525	013	1	1	02	01	H9525_013_1	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	013	2	1	02	01	H9525_013_2	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	013	3	1	02	01	H9525_013_3	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1400.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	013	4	1	02	01	H9525_013_4	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	013	5	1	02	01	H9525_013_5	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	021	1	1	02	01	H9525_021_1	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	021	2	1	02	01	H9525_021_2	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	021	3	1	02	01	H9525_021_3	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	021	4	1	02	01	H9525_021_4	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	021	5	1	02	01	H9525_021_5	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3				2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	022	0	1	01	01	H9525_022_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H9525	027	0	1	01	01	H9525_027_0	4	2				1	20	20	20	2				2		1	2	1		1800.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H9525	028	0	1	01	01	H9525_028_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H9525	801	0	1	01	01	H9525_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9525	802	0	1	01	01	H9525_802_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9525	803	0	2	01	01	H9525_803_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9525	804	0	1	01	01	H9525_804_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9525	805	0	1	01	01	H9525_805_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9525	806	0	2	01	01	H9525_806_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9525	807	0	2	01	01	H9525_807_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9525	809	0	1	01	01	H9525_809_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9525	811	0	2	01	01	H9525_811_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9525	813	0	1	01	01	H9525_813_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9525	815	0	2	01	01	H9525_815_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9525	816	0	2	01	01	H9525_816_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9564	001	0	1	20	08	H9564_001_0	1																																																																																																																																																																																																																																																																																																						
H9564	002	0	1	20	08	H9564_002_0	1																																																																																																																																																																																																																																																																																																						
H9572	001	1	1	04	01	H9572_001_1	10	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	001	2	1	04	01	H9572_001_2	9	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	001	3	1	04	01	H9572_001_3	9	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	001	4	1	04	01	H9572_001_4	9	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	001	6	1	04	01	H9572_001_6	9	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	002	1	1	04	01	H9572_002_1	12	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays-bitewings or periapical	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	002	2	1	04	01	H9572_002_2	11	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays-bitewings or periapical	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	002	3	1	04	01	H9572_002_3	11	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays-bitewings or periapical	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	002	4	1	04	01	H9572_002_4	11	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays-bitewings or periapical	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	002	6	1	04	01	H9572_002_6	11	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays-bitewings or periapical	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	003	1	1	04	01	H9572_003_1	9	2				2				3		0.00	10.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.  Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	003	2	1	04	01	H9572_003_2	8	2				2				3		0.00	10.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.  Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	003	3	1	04	01	H9572_003_3	8	2				2				3		0.00	10.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.  Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	003	4	1	04	01	H9572_003_4	8	2				2				3		0.00	10.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.  Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	003	6	1	04	01	H9572_003_6	8	2				2				3		0.00	10.00	2		2	2	1	2	1500.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.  Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	004	1	1	04	01	H9572_004_1	11	2				2				3		0.00	45.00	2		2	2	1	2	950.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	004	2	1	04	01	H9572_004_2	10	2				2				3		0.00	45.00	2		2	2	1	2	950.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	004	4	1	04	01	H9572_004_4	10	2				2				3		0.00	45.00	2		2	2	1	2	950.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	004	6	1	04	01	H9572_004_6	10	2				2				3		0.00	45.00	2		2	2	1	2	950.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	007	1	1	04	01	H9572_007_1	12	2				2				3		0.00	50.00	2		2	2	1	2	1000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.  Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	007	2	1	04	01	H9572_007_2	12	2				2				3		0.00	50.00	2		2	2	1	2	1000.00	3				2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.  Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	008	0	1	04	01	H9572_008_0	9	2				2				3		0.00	55.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Xray-bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																				
H9572	009	0	1	04	01	H9572_009_0	9	2				2				3		0.00	45.00	2		2	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1							2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	010	0	1	04	01	H9572_010_0	9	2				2				3		0.00	50.00	2		2	2	1	2	750.00	3		2		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	2	2	750.00	3		2		2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	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.	2				2				2	2																3													2	2
H9572	801	0	1	04	01	H9572_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9572	802	0	1	04	01	H9572_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9572	807	0	1	04	01	H9572_807_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9590	001	0	1	01	01	H9590_001_0	7	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9592	001	0	1	20	08	H9592_001_0	1																																																																																																																																																																																																																																																																																																						
H9592	002	0	1	20	08	H9592_002_0	1																																																																																																																																																																																																																																																																																																						
H9615	023	0	1	04	01	H9615_023_0	10	2				2				1	50.00	50.00	50.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																			
H9615	025	0	1	04	01	H9615_025_0	8	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	300.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9615	802	0	1	04	01	H9615_802_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9615	807	0	1	04	01	H9615_807_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9615	810	0	1	04	01	H9615_810_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9615	811	0	1	04	01	H9615_811_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9616	001	0	1	20	08	H9616_001_0	1																																																																																																																																																																																																																																																																																																						
H9616	002	0	1	20	08	H9616_002_0	1																																																																																																																																																																																																																																																																																																						
H9623	001	0	1	01	01	H9623_001_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9630	002	0	1	02	01	H9630_002_0	4	2				2				1	25.00	25.00	25.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H9630	010	0	1	02	01	H9630_010_0	6	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H9630	011	0	1	02	01	H9630_011_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H9630	014	0	1	02	01	H9630_014_0	4	2				2				1	20.00	20.00	20.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	2								2					2																																																																																																																																									2	2	1	6	Every date of service	2				1	0.00	0.00	0.00	1	2
H9649	001	0	1	20	08	H9649_001_0	1																																																																																																																																																																																																																																																																																																						
H9649	002	0	1	20	08	H9649_002_0	1																																																																																																																																																																																																																																																																																																						
H9678	002	0	1	04	01	H9678_002_0	9	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2
H9686	004	0	1	01	01	H9686_004_0	10	2				2				2				2		1	2	2							2				2					2					2		2	1				2				1	10.00	10.00	10.00	1	2	2	1				2				1	30.00	30.00	30.00	1	2																2	1				2				1	20.00	20.00	20.00	1	2	2	1				2				1	10.00	10.00	10.00	1	2																1	2		3500.00	3		2		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H9686	005	0	1	01	01	H9686_005_0	9	2				2				2				2		1	2	1		3700.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H9686	006	0	1	01	01	H9686_006_0	10	2				2				2				2		1	2	1		3700.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H9686	009	0	1	01	01	H9686_009_0	10	2				2				2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H9686	801	0	1	01	01	H9686_801_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H9686	802	0	1	01	01	H9686_802_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H9686	803	0	1	01	01	H9686_803_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H9686	804	0	1	01	01	H9686_804_0	3	2				2				2				2		2	2																																																																																																																																																																																																																																																																																						
H9690	001	0	1	01	01	H9690_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9690	003	0	1	01	01	H9690_003_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9690	004	0	1	01	01	H9690_004_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9699	007	0	1	01	01	H9699_007_0	3	2				2				1	45.00	45.00	45.00	2		2	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	2		3000.00	3		2		2					2		2	2	1	3		1	20	20	20	2				2	2																2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2				2	2	2	2	2	6	Periodicities for covered services range from every year to every five years depending on the service.	1	20	20	20	2				2	2																																														2	1				1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H9700	001	0	1	04	01	H9700_001_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9700	002	0	1	04	01	H9700_002_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9700	003	0	1	04	01	H9700_003_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9700	004	0	1	04	01	H9700_004_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9700	005	0	1	04	01	H9700_005_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9700	006	0	1	04	01	H9700_006_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9700	007	0	1	04	01	H9700_007_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9700	008	0	1	04	01	H9700_008_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9700	009	0	1	04	01	H9700_009_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9706	801	0	1	01	01	H9706_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9706	802	0	1	01	01	H9706_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9706	803	0	1	01	01	H9706_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9725	003	0	1	01	01	H9725_003_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	005	0	1	01	01	H9725_005_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	009	1	1	01	01	H9725_009_1	8	2				2				1	20.00	20.00	20.00	2		1	2	1		1650.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	009	3	1	01	01	H9725_009_3	7	2				2				1	15.00	15.00	15.00	2		1	2	1		1450.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	009	4	1	01	01	H9725_009_4	7	2				2				1	20.00	20.00	20.00	2		1	2	1		1200.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	013	0	1	01	01	H9725_013_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	015	1	1	01	01	H9725_015_1	8	2				2				1	45.00	45.00	45.00	2		1	2	1		700.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	015	3	1	01	01	H9725_015_3	8	2				2				1	45.00	45.00	45.00	2		1	2	1		700.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	015	4	1	01	01	H9725_015_4	7	2				2				1	45.00	45.00	45.00	2		1	2	1		700.00	3				2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	016	0	1	01	01	H9725_016_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	018	0	1	02	01	H9725_018_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	020	0	1	01	01	H9725_020_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		1200.00	3		2		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	801	0	1	01	01	H9725_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9730	003	0	1	02	01	H9730_003_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H9730	004	0	1	02	01	H9730_004_0	5	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to once per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 2 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H9730	007	0	1	02	01	H9730_007_0	4	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	Per tooth per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H9730	009	0	1	02	01	H9730_009_0	4	2				2				1	35.00	35.00	35.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H9730	011	0	1	02	01	H9730_011_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Per visit	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2		2					2		2	2	1	6	Every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every 6 months to 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every year to 5 years	2				1	0.00	0.00	0.00	1	2																																														2	2	1	6	Every tooth or quadrant per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Every date of service to every 5 years	2				1	0.00	0.00	0.00	1	2
H9771	001	0	1	01	01	H9771_001_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H9802	001	0	1	04	01	H9802_001_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9802	002	0	1	04	01	H9802_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9802	004	0	1	04	01	H9802_004_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9802	006	0	1	04	01	H9802_006_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9802	008	0	1	04	01	H9802_008_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9802	009	0	1	04	01	H9802_009_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9802	010	0	1	04	01	H9802_010_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9802	011	0	1	04	01	H9802_011_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9808	004	0	1	04	01	H9808_004_0	9	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2																															1	2	2	750.00	3		2		2					2		2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2
H9808	005	0	1	04	01	H9808_005_0	9	2				2				1	35.00	35.00	35.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2																															1	2	2	1500.00	3		2		2					2		2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2
H9808	009	0	1	04	01	H9808_009_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2																															1	2	2	1250.00	3		2		2					2		2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2
H9808	010	0	1	04	01	H9808_010_0	10	2				2				1	40.00	40.00	40.00	2		2	2	2							2				2					1	111100	20.00	20.00	20.00	2		4	2	2	3		2								2	2	4	2	1	6	see notes	2								2	2	4	2	1	6	see notes	2								2	2	4	2	2	3		2								2	2																																																																																																																																																																																																			
H9811	801	0	1	01	01	H9811_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
H9826	003	0	1	01	01	H9826_003_0	6	2				1	20	20	20	2				2		2	2	1		4500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H9826	004	0	1	01	01	H9826_004_0	6	2				1	20	20	20	2				2		2	2	1		3500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H9826	005	0	1	01	01	H9826_005_0	6	2				1	20	20	20	2				2		2	2	1		4500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H9826	006	0	1	01	01	H9826_006_0	6	2				1	20	20	20	2				2		2	2	1		4500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H9826	007	0	1	01	01	H9826_007_0	6	2				1	20	20	20	2				2		2	2	1		4500.00	3		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H9827	001	0	1	01	01	H9827_001_0	6	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H9827	003	0	1	01	01	H9827_003_0	5	2				2				1	25.00	25.00	25.00	2		2	2	1		1000.00	3		2		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	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		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H9827	004	0	1	01	01	H9827_004_0	6	2				2				1	45.00	45.00	45.00	2		2	2	1		1000.00	3		2		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing, or 1 per consecutive 36 months for comprehensive series.	2				2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	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				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
H9827	801	0	1	01	01	H9827_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9827	802	0	1	01	01	H9827_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9830	001	0	1	20	08	H9830_001_0	1																																																																																																																																																																																																																																																																																																						
H9830	002	0	1	20	08	H9830_002_0	1																																																																																																																																																																																																																																																																																																						
H9834	001	0	1	01	01	H9834_001_0	6	2				2				1	45.00	45.00	45.00	2		2	2	1		475.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H9834	003	0	1	01	01	H9834_003_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1		400.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H9834	004	0	1	01	01	H9834_004_0	4	2				2				1	50.00	50.00	50.00	2		2	2	1		1000.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H9834	006	0	1	01	01	H9834_006_0	6	2				2				1	60.00	60.00	60.00	2		2	2	1		300.00	3		2		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1							2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H9834	007	0	1	01	01	H9834_007_0	6	2				2				1	75.00	75.00	75.00	2		2	2	2							2				2					2					2		4	2	1	2		2				2				2	2	3													2	2	3													2	2	4	2	1	2		2				2				2	2	3													2	2																																																																																																																																																																																				
H9842	001	0	1	20	08	H9842_001_0	1																																																																																																																																																																																																																																																																																																						
H9842	002	0	1	20	08	H9842_002_0	1																																																																																																																																																																																																																																																																																																						
H9862	001	0	1	04	01	H9862_001_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9862	002	0	1	04	01	H9862_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9862	003	0	1	04	01	H9862_003_0	4	2				1	30	30	30	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9862	004	0	1	04	01	H9862_004_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9862	005	0	1	04	01	H9862_005_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9862	009	0	1	04	01	H9862_009_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9862	010	0	1	04	01	H9862_010_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9862	011	0	1	04	01	H9862_011_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9862	012	0	1	04	01	H9862_012_0	4	2				1	30	30	30	2				2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9862	013	0	1	04	01	H9862_013_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9862	014	0	1	04	01	H9862_014_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9862	018	0	1	04	01	H9862_018_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9884	008	0	1	04	01	H9884_008_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9884	013	0	1	04	01	H9884_013_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9884	014	0	1	04	01	H9884_014_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9884	015	0	1	04	01	H9884_015_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9884	016	0	1	04	01	H9884_016_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9884	017	0	1	04	01	H9884_017_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9888	001	0	1	04	01	H9888_001_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H9888	002	0	1	04	01	H9888_002_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H9888	005	0	1	04	01	H9888_005_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9888	006	0	1	04	01	H9888_006_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9888	007	0	1	04	01	H9888_007_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H9888	008	0	1	04	01	H9888_008_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H9888	009	0	1	04	01	H9888_009_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9888	010	0	1	04	01	H9888_010_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				1	2
H9888	011	0	1	04	01	H9888_011_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9888	012	0	1	04	01	H9888_012_0	4	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9888	013	0	1	04	01	H9888_013_0	5	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9888	014	0	1	04	01	H9888_014_0	5	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9888	015	0	1	04	01	H9888_015_0	4	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9907	003	0	1	04	01	H9907_003_0	7	2				2				1	65.00	65.00	65.00	2		1	2																																																																																																																																																																																																																																																																																						
H9907	801	0	1	04	01	H9907_801_0	5	2				2				1	45.00	45.00	45.00	2		1	2																																																																																																																																																																																																																																																																																						
H9907	802	0	1	04	01	H9907_802_0	5	2				2				1	45.00	45.00	45.00	2		1	2																																																																																																																																																																																																																																																																																						
H9907	803	0	1	04	01	H9907_803_0	4	2				2				1	45.00	45.00	45.00	2		1	2																																																																																																																																																																																																																																																																																						
H9907	804	0	1	04	01	H9907_804_0	5	2				2				1	45.00	45.00	45.00	2		1	2																																																																																																																																																																																																																																																																																						
H9909	001	0	1	01	01	H9909_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9917	006	0	1	01	01	H9917_006_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	4	3		2				2				2	2	2	2	4	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	4	3		2				2				2	2	2	2	2	4		2				2				2	2																1	2		4000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9917	007	0	1	01	01	H9917_007_0	8	2				1	20	20	20	2				2		1	2	2							2				2					2					2		2	2	4	3		2				2				2	2	2	2	4	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	4	3		2				2				2	2	2	2	2	4		2				2				2	2																1	2		4000.00	3		2		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9942	001	0	1	04	01	H9942_001_0	7	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
H9942	002	0	1	04	01	H9942_002_0	7	2				2				2				2		1	2																																																																																																																																																																																																																																																																																						
H9955	008	0	1	01	01	H9955_008_0	5	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	Periodic or comprehensive oral evaluation: 1 every 180 days per patient per provider; Comprehensive oral evaluation: 1 every 5 years; Limited oral evaluation-problem focused: 1 per patient per day; Comprehensive periodontal evaluation: 1 per year; Exams limited to 1 per day per provider or location.	2				2				2	2	2	2	1	6	Intraoral periapical radiograph first image: 1 per date of service, up to 12/ year; Additional periapical images: up to 9/ year, max 3 per day; Bitewing radiographs: 1/ 6 months; Occlusal radiographs: up to 4/ year; Comprehensive radiographic series or panoramic or cone imaging: 1/ 5 years.	2				2				2	2																2	2	2	6	1 cleaning every 180 days per patient.	2				2				2	2																															2								2					2		2	2	1	6	Amalgam and composite restorations: 1/tooth/12 months/surface/patient/provider or location; Crowns: 1/tooth/60 months; Prefabricated stainless steel crowns: 1/tooth/60 months; Interim restoration: 1/tooth/180 days; Core buildup: 1/tooth/lifetime; Pin retention: 3/tooth/lifetime.	2				2				1	2	2	2	1	6	Root canal therapy (anterior, premolar, molar): 1 per tooth per lifetime.	2				2				1	2	2	2	1	6	Scaling and root planing: 1 per quadrant every 24 months; Gingivectomy or gingivoplasty: 1 per quadrant every 24 months; Periodontal maintenance: 2 per year.	2				2				1	2	2	2	1	6	Complete, immediate, and partial dentures: 1 every 96 months; Denture repairs: 1 per arch every 3 years; Denture relines: 1 every 36 months (not covered within 36 months of placement).	2				2				1	2																																														2	2	1	6	Extractions, erupted tooth:  1 per tooth per lifetime; Surgical removal of impacted teeth: 1 per tooth per lifetime; Exposure of unerupted tooth: 1 per tooth per lifetime; Alveoloplasty: 1 per quadrant per lifetime; Biopsy: 1 per year.	2				2				1	2																2	2	1	6	Deep sedation/general anesthesia: 1 initial increment plus up to 4 additional increments per day; Moderate IV sedation: 1 initial increment plus up to 4 additional increments per day; Nitrous oxide: 1 per day; Therapeutic drug administration: 1 per day.	2				2				1	2
H9955	009	0	1	01	01	H9955_009_0	6	2				1	20	20	20	2				2		2	2	2							2				2					2					2		2	2	2	6	Periodic or comprehensive oral evaluation: 1 every 180 days per patient per provider; Comprehensive oral evaluation: 1 every 5 years; Limited oral evaluation-problem focused: 1 per patient per day; Comprehensive periodontal evaluation: 1 per year; Exams limited to 1 per day per provider or location.	2				2				2	2	2	2	1	6	Intraoral periapical radiograph first image: 1 per date of service, up to 12/ year; Additional periapical images: up to 9/ year, max 3 per day; Bitewing radiographs: 1/ 6 months; Occlusal radiographs: up to 4/ year; Comprehensive radiographic series or panoramic or cone imaging: 1/ 5 years.	2				2				2	2																2	2	2	6	1 cleaning every 180 days per patient.	2				2				2	2																															2								2					2		2	2	1	6	Amalgam and composite restorations: 1/tooth/12 months/surface/patient/provider or location; Crowns: 1/tooth/60 months; Prefabricated stainless steel crowns: 1/tooth/60 months; Interim restoration: 1/tooth/180 days; Core buildup: 1/tooth/lifetime; Pin retention: 3/tooth/lifetime.	2				2				1	2	2	2	1	6	Root canal therapy (anterior, premolar, molar): 1 per tooth per lifetime.	2				2				1	2	2	2	1	6	Scaling and root planing: 1 per quadrant every 24 months; Gingivectomy or gingivoplasty: 1 per quadrant every 24 months; Periodontal maintenance: 2 per year.	2				2				1	2	2	2	1	6	Complete, immediate, and partial dentures: 1 every 96 months; Denture repairs: 1 per arch every 3 years; Denture relines: 1 every 36 months (not covered within 36 months of placement).	2				2				1	2																																														2	2	1	6	Extractions, erupted tooth:  1 per tooth per lifetime; Surgical removal of impacted teeth: 1 per tooth per lifetime; Exposure of unerupted tooth: 1 per tooth per lifetime; Alveoloplasty: 1 per quadrant per lifetime; Biopsy: 1 per year.	2				2				1	2																2	2	1	6	Deep sedation/general anesthesia: 1 initial increment plus up to 4 additional increments per day; Moderate IV sedation: 1 initial increment plus up to 4 additional increments per day; Nitrous oxide: 1 per day; Therapeutic drug administration: 1 per day.	2				2				1	2
H9968	001	0	1	01	01	H9968_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																						
H9977	001	0	1	01	01	H9977_001_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		2750.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9977	002	0	1	01	01	H9977_002_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9977	003	0	1	01	01	H9977_003_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9977	004	0	1	01	01	H9977_004_0	4	2				1	30	30	30	2				2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9977	005	0	1	01	01	H9977_005_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9977	006	0	1	01	01	H9977_006_0	4	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				2	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				2	2
H9977	007	0	1	01	01	H9977_007_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																2	2	1	6	Plan covers implant maintenance services once every year	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9977	012	0	1	01	01	H9977_012_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9977	013	0	1	01	01	H9977_013_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9977	015	0	1	01	01	H9977_015_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9977	016	0	1	01	01	H9977_016_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1							2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers dentures (once every five years)	1	50	50	50	2				2	2																2	2	1	6	Plan covers implant maintenance services once every year	1	50	50	50	2				2	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	1	50	50	50	2				2	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	1	50	50	50	2				2	2
H9986	001	0	1	01	01	H9986_001_0	8	2				1	20	20	20	2				2		2	2	1		912.50	5		2		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2																2	1				2				2				2	2	1	1							2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9986	002	0	1	02	01	H9986_002_0	8	2				1	20	20	20	2				2		2	2	1		862.50	5		2		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				1	2																2	1				2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H9986	004	1	1	02	01	H9986_004_1	9	2				1	20	20	20	2				2		2	2	1		1165.00	5				2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				1	2																2	1				2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H9986	004	2	1	02	01	H9986_004_2	8	2				1	20	20	20	2				2		2	2	1		1095.00	5				2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				1	2																2	1				2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H9986	004	3	1	02	01	H9986_004_3	5	2				1	20	20	20	2				2		2	2	1		1025.00	5				2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				1	2																2	1				2				2				1	2	1	1							2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H9998	001	0	1	20	08	H9998_001_0	1																																																																																																																																																																																																																																																																																																						
H9998	002	0	1	20	08	H9998_002_0	1																																																																																																																																																																																																																																																																																																						
R0110	001	0	1	31	11	R0110_001_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	6000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	003	0	1	31	11	R0110_003_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
R0110	004	0	1	31	11	R0110_004_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	005	0	1	31	11	R0110_005_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
R0110	006	0	1	31	11	R0110_006_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
R0110	007	0	1	31	11	R0110_007_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
R0110	008	0	1	31	11	R0110_008_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
R0110	011	0	1	31	11	R0110_011_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	012	0	1	31	11	R0110_012_0	4	2				2				1	55.00	55.00	55.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
R0110	013	0	1	31	11	R0110_013_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	014	0	1	31	11	R0110_014_0	4	2				2				1	60.00	60.00	60.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2																																														2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
R0110	015	0	1	31	11	R0110_015_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	016	0	1	31	11	R0110_016_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
R0110	017	0	1	31	11	R0110_017_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	018	0	1	31	11	R0110_018_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
R0110	019	0	1	31	11	R0110_019_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
R0110	020	0	1	31	11	R0110_020_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
R0110	801	0	1	31	11	R0110_801_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	802	0	1	31	11	R0110_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	804	0	1	31	11	R0110_804_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	805	0	1	31	11	R0110_805_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	806	0	1	31	11	R0110_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	807	0	1	31	11	R0110_807_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	808	0	1	31	11	R0110_808_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	809	0	1	31	11	R0110_809_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	810	0	1	31	11	R0110_810_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	811	0	1	31	11	R0110_811_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	812	0	1	31	11	R0110_812_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	813	0	1	31	11	R0110_813_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	814	0	1	31	11	R0110_814_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	815	0	1	31	11	R0110_815_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	816	0	1	31	11	R0110_816_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0110	817	0	1	31	11	R0110_817_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R0759	001	0	1	31	11	R0759_001_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
R0759	002	0	1	31	11	R0759_002_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
R0759	003	0	1	31	11	R0759_003_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
R0759	801	0	1	31	11	R0759_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
R1532	001	0	1	31	11	R1532_001_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
R1532	002	0	1	31	11	R1532_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
R1532	801	0	1	31	11	R1532_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R1532	802	0	1	31	11	R1532_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R2604	002	0	1	31	11	R2604_002_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1							2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	2	2
R2604	005	0	1	31	11	R2604_005_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
R2604	801	0	1	31	11	R2604_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
R3175	807	0	1	31	11	R3175_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
R3444	803	0	1	31	11	R3444_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
R4182	001	0	1	31	11	R4182_001_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R4182	003	0	1	31	11	R4182_003_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
R4182	004	0	1	31	11	R4182_004_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
R4182	801	0	1	31	11	R4182_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R4182	802	0	1	31	11	R4182_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R5342	805	0	1	31	11	R5342_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
R5361	001	0	1	31	11	R5361_001_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	30	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	30	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	30	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	30	30	30	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	30	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	30	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	30	30	30	2				1	2
R5361	002	0	1	31	11	R5361_002_0	4	2				1	20	20	20	2				2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
R5361	801	0	1	31	11	R5361_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R5361	802	0	1	31	11	R5361_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R5826	005	0	1	31	11	R5826_005_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	750.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
R5826	018	0	1	31	11	R5826_018_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	8	6	extractions 1/tooth/lifetime, oral surg 4/yr, oral surgery - other 2/tooth/lifetime, oral surgery - repair of tissue defect unl/yr, vestibuloplasty 1/5 yrs	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R5826	074	0	1	31	11	R5826_074_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2																																2	2	4	3		2				1	0.00	0.00	0.00	1	2																																																																																											2	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
R5826	805	0	1	31	11	R5826_805_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R5826	819	0	1	31	11	R5826_819_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R5941	013	0	1	31	11	R5941_013_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1750.00	3		2		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1							2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
R5941	014	0	1	31	11	R5941_014_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
R5941	016	0	1	31	11	R5941_016_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2							2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																				
R6694	006	0	1	31	11	R6694_006_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																			
R6801	009	0	1	31	11	R6801_009_0	4	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
R6801	011	0	1	31	11	R6801_011_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
R6801	012	0	1	31	11	R6801_012_0	3	2				1	20	20	20	2				2		1	2	2							2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																					
R7220	001	0	1	31	11	R7220_001_0	7	2				2				1	50.00	50.00	50.00	2		1	2	1	2	3000.00	3		2		2				2					2					2		2	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	2	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1							2					2		2	2	4	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/5 yrs, crown recement 1/2 yrs, filling 1 per tooth per surface/2 yrs	3		0	50	2				1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	3		0	50	2				1	2	2	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	3		0	50	2				1	2	2	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and framework 2/yr, denture repair - additions 1/tooth/5 yrs, denture repair - broken teeth 2/tooth/yr, rebase, reline, tissue cond 1/yr	1	50	50	50	2				1	2																															2	2	4	6	bridge recement 1/yr, bridges-crown-porc w/ high noble metal, bridges-crown-porc w/ noble metal, bridges-crown-porcelain/ ceramic 2/5 yrs, bridges-pontic 1/5 yrs	3		0	50	2				1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																2	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	1	50	50	50	2				1	2
R7220	002	0	1	31	11	R7220_002_0	6	2				2				1	50.00	50.00	50.00	2		1	2	2							2				2					2					2		4	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	2				1	0.00	0.00	0.00	2	2	4	2	2	6	bitewing x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2																															2								2					2		3													2	2	3													2	2	4	2	4	3		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	2	1	6	necessary nitrous oxide/analgesia with covered service 1 unit/visit	2				1	0.00	0.00	0.00	1	2
R7220	801	0	1	31	11	R7220_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R7220	802	0	1	31	11	R7220_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																						
R7444	809	0	1	31	11	R7444_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																						
